Call Light Reset Button Taped Down, Disabling Resident Call System
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s call bell system remained functional at all times, as required by its call system policy. The policy stated that each resident must have a means to call staff from the bed and toileting/bathing areas, and that the call system must remain functional, whether audible or visual. For one resident with diagnoses including right pubic fracture, repeated falls, Parkinson’s disease, and paraplegia, the call light in the resident’s room was found to be nonfunctional because the reset button had been taped down, preventing the call light from working properly. On the date of the incident, a family member reported that the resident had been calling for help and no one answered the call light. The family member notified a nurse that the call light was not working. The nurse reported that she checked the call light by unplugging and re-plugging both call light cords in the room and found them to be working at that time. She told the family member that the call light appeared to be functioning and stated she would call maintenance if it was not working, and she also offered a handheld bell for the resident, which the family member refused according to the nurse’s account. Later that same day, the family returned and again found that the call light was not working when pressed multiple times. Another family member then pressed the call light reset button and observed that it had been taped down with several pieces of clear tape, which would prevent the system from activating. This was reported to the nurse, who went to the room, confirmed that clear tape was over the reset button, and immediately removed it. The nursing supervisor and DON were subsequently informed that tape had been found over the reset button. The maintenance director later confirmed that if tape or any pressure is placed over a call light reset button, the call light would not work or light up to call staff for assistance. Despite review of staff statements and surveillance footage, facility leadership could not determine who placed the tape on the reset button or when it was applied, but the result was that the resident’s call system was disabled and not functioning as required by facility policy.
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