Failure to Maintain Functional Resident Call System
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident in her room, resulting in the resident being unable to reliably summon staff assistance. The resident, who had a history of cervical disc disorder, spinal fusion, osteoporosis, and anxiety, required substantial assistance with toileting and was at moderate risk for falls. Despite repeated reports from the resident that her call light was malfunctioning—sometimes not working at all or only intermittently functioning—maintenance checks did not resolve the issue, and the problem persisted for approximately two weeks. Multiple staff interviews confirmed that the call light in the resident's room was unreliable, with some staff noting a possible wiring shortage and delays in response. The resident reported waiting for up to two hours for assistance and ultimately called 911 to have emergency services contact the facility on her behalf. Staff acknowledged the ongoing issue, with maintenance staff indicating that a technician should have been called to inspect the system, but no documentation of repairs or technician visits was provided. The resident was offered a room change, which she declined, and was eventually provided with a manual call bell as a temporary solution. Facility policy required that the call system remain functional at all times and that calls for assistance be answered within five minutes. However, the resident's repeated complaints and the lack of timely resolution to the malfunctioning call light system demonstrated a failure to meet these standards. The deficiency was substantiated through observations, interviews, and record reviews, which consistently indicated that the resident did not have reliable access to staff assistance through the required communication system.