Failure to Provide Functional Nurse Call System for Resident Assistance
Penalty
Summary
The facility failed to ensure that a reliable and effective nurse call system was available and functional for residents, specifically impacting a resident with significant respiratory needs. The call system in the resident's room and bathroom only activated a visual hallway light, with no audible alert to the nurse station or hallway, and the hallway lights were not visible from the nurse station. Staff interviews confirmed that the system did not provide audible alerts and that staff relied on visually monitoring hallway lights, which could not always be seen if staff were in other rooms or areas. Staff and residents had previously complained about the call system, but these concerns were not communicated to the administrator, DON, or maintenance staff. A resident with chronic respiratory conditions, including COPD and respiratory failure, experienced shortness of breath and attempted to call for assistance using the call light system. No staff responded, leading the resident to call 911 for help. Emergency medical personnel arrived and found that the nurse call system did not provide adequate notification to staff, as only a light above the door was activated without an audible alert. The EMTs had to contact the facility's front desk to alert staff to the resident's needs. The resident reported feeling that her oxygen supply was inadequate at the time and could not recall staff responding to her activated call light. Observations by the surveyor confirmed that the nurse call system in multiple rooms only activated a visual hallway light, with no audible alert in the hallway and only a low audible alert at the nurse station. Maintenance logs showed no repairs to the call light system in the 30 days prior to the incident, and the administrator and DON were unaware of any ongoing issues. Staff interviews indicated that the lack of an effective call system limited their ability to respond promptly to residents' needs, particularly for those with urgent medical conditions.