Failure to Maintain Accessible Bathroom Call Light for Independent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a working and accessible call light system was available in a resident's bathroom and bathing area. The resident involved had an above-the-knee amputation of the left leg and was assessed as cognitively intact and independent with transfers, bed mobility, toileting, and other ADLs. On multiple observations over three consecutive days, the bathroom call light for this resident was found without an attached pull cord. The resident confirmed that there was no pull cord in the bathroom, could not recall when it was last present, and stated that if he were lying on the floor, he would be unable to use the call light for assistance. Staff interviews showed that nursing assistants and the occupational therapist considered the resident independent in daily care tasks, with assistance only needed for showers. The Facility Maintenance Director reported having a preventative maintenance program but stated it had not been completed and that he was unaware of the missing pull cord because no one had notified him or entered a request in the engineering book. Review of the engineering book showed no service request for the missing pull cord during the specified period. The Environmental Service Manager used a weekly checklist that did not include call lights or pull cords and did not notice the missing pull cord during her room rounds. The DON and Administrator both stated they were unaware of the missing pull cord and indicated that staff were expected to communicate such issues to maintenance via the engineering book or direct calls, but this did not occur in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.