Failure to Maintain Functional Call Light System for Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to maintain a working call light system in a resident’s bathroom and bathing area. One resident with diagnoses including Type 2 diabetes and fractures of the left tibia and fibula was cognitively intact and required partial to moderate assistance for toileting, with a care plan noting an ADL self-care performance deficit related to right leg fractures. During an interview, the resident reported that her call light had not been working for 3–4 days and demonstrated that pressing the call light button did not activate the corridor light. The resident stated that, due to the nonfunctioning call light and the absence of a Maintenance Supervisor, staff were supposed to check on her more frequently, and that while day shift staff checked on her often, night shift staff did not, resulting in her having to yell for help during the night. Staff interviews and maintenance information further described the extent and duration of the call light problem. An LPN reported that the resident’s call light was not working on the previous day and that staff were checking on the resident at least hourly. The DON stated she became aware that morning that the resident’s call light was not working and believed it had stopped working that day. The Corporate Maintenance Supervisor acknowledged awareness that the resident’s call light was not working, was unsure how long it had been out, and reported having replaced a battery in part of the unit two days earlier. He also stated there had been issues with call lights in other areas of the building not working the prior week and that some call lights in empty rooms were currently not working. The facility’s undated Call Light Policy required that all residents able to use a call light have the system available and accessible at all times, that call bell system defects be promptly reported to Maintenance, and that hourly room checks occur until the system is repaired.
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