Failure to Provide Timely Assistance Due to Ineffective Nurse Call System
Penalty
Summary
The facility failed to provide timely assistance to a resident with a history of COPD, congestive heart failure, and anxiety when she experienced shortness of breath and required staff assistance. The resident activated her call light for help but did not receive a response from staff, leading her to call 911 for emergency assistance. Upon arrival, EMTs found that the nurse call system only activated a visual light above the resident's door, with no audible alert in the hallway or at the nurse station, making it difficult for staff to be aware of calls for help. Interviews with staff revealed that the nurse call system had been previously repaired, but the audible alerts were still not functioning, and staff relied solely on visual cues, which were not always visible from the nurse station or other areas. Staff and residents had previously complained about the call light system, but these concerns were not communicated to the administrator, DON, or maintenance staff. The lack of an effective alert system limited staff's ability to monitor and respond promptly to resident needs, particularly for those with respiratory conditions. The resident's care plan included interventions for monitoring respiratory status and responding to signs of distress, but these were not effectively implemented due to the call system's deficiencies. The facility's policy required a functional and responsive call light system, but observations and interviews confirmed that the system did not meet these requirements at the time of the incident. There was no evidence of a specific policy for residents with respiratory needs, and maintenance logs did not reflect any repairs to the call light system during the relevant period.