Failure to Maintain Functional Call System in Shower Rooms
Penalty
Summary
The facility failed to ensure that a functional call system was available in resident bathrooms and bathing areas, specifically in both shower rooms at station 2 and station 3. During an observation and interview in the station 3 shower room with the Maintenance Supervisor (MS), surveyors noted there was no call system present for residents using the toilet or shower. The MS confirmed there was no call system available and stated there should have been an alternative call system provided for residents in these areas. In the station 2 shower room, a black wireless call button with a bell logo was observed hanging on the handrail next to the toilet. When the MS pressed this button and then went to nurses station 1, no alarm was heard, and the MS acknowledged that an alarm should have sounded to alert staff that assistance was needed in the shower room. The MS reported that he would replace the black wireless call buttons in the shower rooms but that these buttons would go missing, and reiterated that there should have been a functional call system available for residents using the toilet and shower. The DON stated that the facility had two shower rooms (station 2 and station 3) and that the call system in these shower rooms had not been working, describing it as an ongoing issue. The DON confirmed that residents using the toilet in the station 3 shower room, including Resident 85 and Resident 14, were at risk for falls and that the absence of a call system in the shower rooms would put residents at risk for accidents and falls. Resident 85’s Morse Fall Scale (MFS), dated 12/9/25, showed a score of 55, indicating high fall risk, and Resident 14’s MDS showed a BIMS score of 6, indicating severe cognitive impairment, with an MFS score of 60. Resident 14 reported independently using the toilet in the station 3 shower room and stated there was no call system there. The facility’s policy titled “Communication – Call System” required the facility to provide a call system in resident rooms and toileting/bathing facilities and identified bathroom call bells as emergency calls that must be answered promptly.
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