Failure to Maintain Functional Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system for all residents on one hall, affecting 28 residents whose rooms were connected to a faulty call light panel. Multiple residents reported that their call lights had not worked since the previous day and that this was a recurrent problem over the past month. One cognitively intact resident who required moderate to maximal assistance with ADLs demonstrated that pressing his call light did not activate a signal outside his door or at the nurses’ station and stated he had no way to get assistance or help in an emergency. Another cognitively intact resident who required touch to substantial assistance with ADLs reported significant difficulty obtaining toileting assistance due to the nonfunctioning call light and described having to yell or bang on the wall to get staff attention. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed yelling repeatedly for help with hydration without staff response. Staff interviews confirmed that the call lights for the unit had stopped working the previous afternoon and that this had occurred multiple times in the prior month. A CNA assigned to the affected hall stated that when she started her morning shift, the room call lights were not working and that she had not been given instructions on how residents would be monitored while the system was down. Maintenance staff reported that the main call light panel at the nurses’ station had a missing wiring connection, that they had just rewired it, and that the wiring problem had recurred at least three times in the past month. The Maintenance Director acknowledged that some rooms’ call lights had stopped working, that an outside vendor had been called previously, and that there were no work order logs for the call light issues. An untitled facility document showed 30‑minute rounding for a limited time period on one date but did not specify which residents were rounded on, what type of rounds were done, or any entries covering the time from when the call lights again stopped working through the following morning, despite the facility’s policy requiring prompt reporting of call bell system defects and room checks until repair.
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