Failure to Maintain Functional and Accessible Call Light System
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights were functional and accessible in multiple rooms and bathrooms, affecting at least six identified residents and additional rooms on the Transitional Care Unit. Surveyors observed several residents in bed over extended periods with call lights either out of reach, hidden under blankets, or looped over wall junction boxes across the room. One resident’s call light was repeatedly found under the covers or hanging over the headboard, while another resident reported their call light did not work and was instead provided a hotel-style desk bell that did not reliably ring or summon staff. Another resident’s call light was placed behind the head of the bed or at the shoulder where the resident could not reach it, and yet another resident pressed their call light multiple times without staff response. Additional residents had their call light cords looped over wall boxes far from the bed and were also given hotel-style bells, which did not consistently function when tested. Surveyors further noted that the central call monitoring station in the nurse office displayed activated room numbers but produced no audible chime, and corridor door lights did not illuminate when call lights were activated. During testing with the Maintenance Director, all tested call lights registered visually on the nurse office monitor but none triggered an audible sound, including one room that had been activated for 20 minutes. An LPN reported that the call lights had not been audible for months, that only one nurse was assigned to care for 17 to 24 patients on the unit, and that the call light system had not worked properly for more than six months. The facility’s written call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system itself. The administrator reported being unaware of the call light problem.
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