F0919

D

Failure to Ensure Functioning Call Light System for Resident

Evergreen Park, Illinois Survey Completed on 01-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a working call light system for a resident’s bed, as required by the resident’s care plan and the facility’s call light policy. The resident is an adult male with end stage renal disease, heart transplant status, depression, type 2 diabetes mellitus without complications, and essential hypertension. His care plan, initiated on 12/31/2025, includes an intervention that he be provided a safe environment with a working and reachable call light as part of fall prevention. On 1/2/2026 at 12:41 p.m., the resident was observed sitting in a chair in his room, alert and able to make his needs known, repeatedly calling out for help because he needed assistance getting back to bed.

The resident reported that he had been pressing his call light as instructed but was not receiving help because the call light was not working and the light did not come on. The surveyor observed the resident pressing the call light and confirmed that the corridor light above the door did not illuminate, the light on the call light panel was not on, and there was no audible sound. When informed, a restorative aide entered the room, observed the resident pressing the call light, and stated that the light should illuminate outside the door and that residents use the call light to let staff know they need help. An agency LPN attempted to re-plug the call light and determined that the call light for both bed one and bed two was not working and that maintenance would need to be called.

The maintenance assistant later examined the call light and stated that when the button is pressed, the light is supposed to come on over the door, and that both call lights for bed one and two go into one unit so if one does not work, the other will not work. He reported that he had previously fixed this call light the Saturday before Christmas, that it had come off the wall, and that it must have come loose again. Upon further inspection, he found the call light was not connected and that a wire needed to be soldered back, confirming that neither call light would work. Staff interviews revealed inconsistent understanding of how residents would obtain help if a call light was not functioning, with both a CNA and an agency LPN acknowledging they would not know a resident needed help without a working call light. The DON and nurse manager described expectations for rounds and for reporting defective call lights, and the assistant administrator and maintenance assistant referenced routine checks and alternative measures such as bells or room changes, but the maintenance log for 12/30 only showed a checked box for a call light request in this resident’s room without documentation of what was fixed or the nature of the concern, despite the facility’s policy requiring that the call system be in proper working order and that nonfunctional call lights be addressed and alternative means provided.