F0676

E

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

Kansas City, Missouri Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that the call light system operated as designed, that call lights were accessible to residents, and that call lights were answered in a timely manner, as required by facility policy and resident care plans. The facility’s written policy required a functioning call system at each bedside, toilet, and bathing area, with alerts either directly to staff or to a centralized location, and required staff to keep call lights within reach and respond promptly. Review of the Device Activity Report for one hall over several weeks showed an average call light response time of approximately 70 minutes, with many individual calls taking from over 20 minutes to many hours, including one documented response time of over 1,100 minutes. Staff interviews confirmed that there were no audible or visual hallway alerts, that staff relied solely on a computer screen at the nurse’s station, and that the sound on the system was often turned down.

Multiple residents with significant mobility, respiratory, and ADL deficits reported prolonged waits for assistance and difficulty accessing call lights. One cognitively intact resident with hemiplegia, polyneuropathy, foot drop, generalized muscle weakness, unsteadiness, and a history of falls stated that call lights were sometimes not answered for hours, including waits of up to 5 hours, and reported having to call 911 from a cell phone because staff did not respond. Device Activity Reports for this resident documented several extended response times, including one of 350 minutes. Another cognitively intact resident with COPD, anxiety, and depression, on continuous oxygen, reported waiting up to 3 hours for call lights to be answered, including episodes where oxygen ran out and assistance was delayed until the next shift. A third cognitively intact resident with hemiplegia, COPD, acute respiratory failure with hypoxia, and a history of falls reported that staff took hours to answer call lights, that family and friends had to seek staff for help with shortness of air, and that there were times when no one came until the next shift; this resident also reported incontinence episodes because staff did not respond.

Additional residents with significant physical and cognitive impairments experienced similar issues. One cognitively intact resident with hemiplegia, difficulty walking, muscle weakness, need for personal care assistance, and repeated falls reported waiting hours for call lights to be answered, sometimes being unable to reach the call light, and remaining in urine and/or bowel for hours before being changed; this resident was observed attempting to transfer from a wheelchair to bed without being able to reach the call light. A resident with severe cognitive impairment, COPD, dysphagia, incontinence, and continuous oxygen was observed in bed with the door closed, unable to reach the call light, coughing, choking on saliva, and short of breath; this resident reported often being unable to reach the call light, waiting hours for help, and lying in urine and bowel for hours when staff did not respond. Another resident with multiple sclerosis, muscle weakness, reduced mobility, hemiplegia, and need for total assistance reported that call lights were on for over 30 minutes and often for multiple hours, including one episode where a call light activated at about 1:00 a.m. was not answered until nearly 8:00 a.m., during which the resident lay in urine. During observation, this resident’s call light had been on for over 30 minutes with no hallway light or audible alert, while a CNA sat at the nurse’s station using a cell phone until prompted by another CNA to answer the light.

Staff interviews corroborated that the call light system did not provide adequate audible or visual alerts and that response expectations were not met. A CNA stated that the call light system was broken, that staff only knew a call was active if they were looking at the computer screen at the nurse’s station, and that there were no lights above resident rooms or sounds in the hallways when call lights were activated. An RN reported that CNAs were expected to answer call lights within 10 minutes but that staff only knew about calls by looking at the nurse’s station screen, with no lights or sounds elsewhere, and acknowledged extended call light times. An LPN stated that policy required call lights to be answered within 10 minutes, that the computers at the nurse’s station were the only alert mechanism, and that the sound on the system was often turned down. These observations, interviews, and records demonstrate that the facility failed to maintain a functional, accessible call light system and failed to ensure timely staff response to call lights for multiple residents with significant ADL, mobility, and respiratory needs.