Failure to Maintain Functioning Resident Call Light System
Penalty
Summary
The facility failed to maintain a functioning resident call light system in multiple resident halls, resulting in residents being unable to effectively summon staff assistance. Observations revealed that while corridor call lights illuminated when activated by residents, there was no audible alert in the resident rooms or at the nurse's stations. Multiple instances were documented where residents activated their call lights, but the system failed to ring or alert staff, and no staff were present at the nurse's station to visually monitor the corridor lights. Staff members, including nurses and CNAs, were observed performing other duties such as medication administration and meal tray collection, further reducing the likelihood of timely response to resident needs. Interviews with staff indicated a lack of awareness and communication regarding the malfunctioning call light system. Some staff members noticed that the call lights only rang once or not at all, but did not report these issues to the Maintenance Director. The Maintenance Director himself was unaware of the ongoing problems until prompted by the surveyor and only initiated contact with the call light system vendor after the issue was brought to his attention. Documentation of monthly QA checks indicated that the system was previously reported as functioning, but these checks did not identify the current widespread failure. Further interviews revealed that the central receiver panels at the nurse's stations were nonfunctional, described as "fried," and had not been working for an undetermined period. Staff and confidential sources reported that the system had been inoperable for several months, requiring staff to visually monitor corridor lights as a workaround. The facility's policy required immediate notification and alternative arrangements in the event of a call light outage, but these procedures were not effectively implemented, as evidenced by the lack of timely reporting and the absence of alternative communication methods for residents.