F0919

D

Nonfunctional Call Light and Inadequate Access to Call System

Richland Hills, Texas Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that the resident call system remained functional and accessible for a resident who required staff assistance for mobility and self-care. The resident was an adult male with limitations of activities due to disability, hemiparesis, impaired mobility and balance, cognitive deficits, and severely impaired cognition with a BIMS score of 5. His comprehensive care plan identified risk for falls and included an intervention to ensure his call light was within reach and that he was encouraged to use it for assistance. During observation, the resident was found lying in bed with a call bell placed on the bedside table, while the wall-mounted call light was connected at the foot of the bed. The resident reported that staff did not always come when he rang the bell and that his call light did not work, though he was unsure how long it had been nonfunctional.

When the LVN checked the call light, it did not activate the hallway indicator, confirming it was not working. The LVN stated she had been unaware of the malfunction. The Maintenance Director reported there was no work order for the call light and that he had only just been informed of the issue. A CNA stated she did not know when the call light had stopped working and that, when it broke, the resident had been given a separate call bell that staff recognized by sound. The DON and ADON both stated they were unaware that the resident’s call light was not working and acknowledged the importance of the call light for the resident to communicate needs. The Administrator stated they knew there was a problem and that the resident had a bell in his room. The facility’s policy required that the resident call system remain functional at all times, with audible or visual communication maintained at effective levels, which was not met in this situation.