F0558

E

Failure to Maintain Audible Call Light System and Timely Response to Resident Calls

Pomona, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the call light system was audible and that call lights were answered in a timely manner, resulting in unmet needs for two residents. Resident 1 was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills and decision-making capacity, and was dependent on staff for most ADLs, including transfers. Resident 1 reported that when using the call light, no one came or it took a long time for staff to respond, causing the resident to feel ignored. On one observation outside Resident 1’s room, the call light remained on and unanswered for 25 minutes. In a concurrent observation and interview inside the room, Resident 1 stated the call light had been on for over 30 minutes without response, and that the resident wanted assistance for dry mouth and thirst.

Resident 2, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs, including transfers, and was documented as alert and oriented. Resident 2 stated there was no point in using the call light because nursing staff did not answer it, and that whenever the call light was pushed, no one came to see what was needed. Resident 2 reported feeling that staff did not care and had forgotten about the resident, and expressed concern that an emergency could occur without staff awareness. These resident interviews demonstrated that their calls for assistance were not being reliably answered.

Staff interviews and observations further showed that the call light system was not functioning audibly as intended. A CNA reported answering Resident 1’s call light only because the blinking light above the door was seen, not because the call light was heard, and the CNA did not know how long the light had been on. An LVN stated that call lights should be answered promptly by all staff and that if the responding staff member could not assist, they should notify someone who could, emphasizing that unanswered call lights could delay care and potentially cause life-threatening situations. During testing of call lights on two units, the LVN demonstrated that activating call lights in random rooms did not produce an audible sound at the nurses’ station or in the hallway, despite the DON’s description that each unit’s nurses’ station should have a call light sound box that beeps when a call light is on. Facility policies on answering call lights and accommodation of needs required timely response to residents’ requests and prompt reporting of defective call lights, but the observations and interviews showed these requirements were not met.