F0558

D

Failure to Ensure Working Call Lights for Multiple Residents

Chicago, Illinois Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents had working call lights to reasonably accommodate their needs and preferences, as required by their care plans and facility policy. One resident, a cognitively intact female with multiple diagnoses including bilateral lower leg fractures, COPD, malnutrition, incontinence, and high fall risk, was admitted to her current room on 12/29/2025. Her care plan included multiple interventions requiring that the call light be placed within reach and that staff assess her ability to use it, particularly due to her functional deficits, incontinence, and fall risk. On observation, she was bedridden, unable to bear weight on her legs, and dependent on staff for all assistance, yet she reported that her call light had not worked since admission to the room. When she pressed the call light during the survey, there was no light at the panel, no light outside the room, and no audible sound.

The same resident stated that when her roommate was present, the roommate would either press her own call light or walk to the nurses’ station to get help, but when the roommate was not present, the resident had to wait and became scared that no one would come when she needed help. The bathroom shared by these two residents had no call panel or pull switch. The roommate, also cognitively intact and with multiple medical and psychiatric diagnoses, confirmed that staff did not answer call lights consistently and that the other resident’s call light did not work. She demonstrated that her own call light functioned, while the bedridden resident’s did not, and she stated that if she needed help in the bathroom, there was no call light to pull. The Director of Nursing observed that the bedridden resident’s call light did not activate any lights and acknowledged that the resident was dependent on staff and required a working call light. The DON stated that if a call light was not working, the resident should have been given a bell, and that clinical staff do not check call lights, even though call lights should be working.

A third cognitively intact male resident with a history of stroke, hemiplegia, incontinence, and high fall risk also reported that his call light did not work and that he relied on his roommate to get staff when he needed assistance. His care plan required that the call light be placed within easy reach to maintain his dignity related to incontinence and that he be educated to use the call light for assistance with ADLs as part of his fall prevention interventions. During observation, when he pressed his call light, there was no light at the wall panel, no light above the room, and no audible sound. The call light was not answered, and when an LPN entered to give medications, she did not acknowledge the call light because it was not functioning. When the LPN later tested the call light, it did not work until she unplugged and reinserted it several times, after which it began to function. She stated that nurses and CNAs are supposed to ensure call lights are working, keep them within reach, and submit work tickets for nonfunctioning call lights so they can be fixed immediately.

Interviews with staff revealed inconsistencies between stated procedures and actual practice. The Assistant DON stated that call lights are checked every day and that frequent rounds are made to ensure residents are checked, while the Maintenance Director stated that rooms are checked daily by housekeeping and CNAs, that any nonworking equipment should be entered into the system to alert maintenance, and that every bed should have a functioning call light. The Maintenance Director acknowledged that the bedridden resident’s call light had been a “constant issue,” that management knew in morning meetings that the call light was not working, and that someone should have provided the resident with some type of communication device. The facility’s Preventive Maintenance Policy required monthly surveillance of all resident rooms for proper operation of equipment, and the Call Light Response policy required prompt reporting of defective call lights. The Maintenance Director’s job description required periodic rounds to check equipment and ensure it was working properly. Despite these policies and stated expectations, multiple residents had nonfunctioning call lights and lacked bathroom call devices, and staff either were unaware of the problems or did not ensure timely reporting and resolution, resulting in residents’ needs not being reasonably accommodated through access to working call lights.