Failure to Maintain Functioning Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system that remained active until staff responded, affecting resident bathrooms and bathing areas and potentially all 37 residents. A resident’s daughter reported via email that her mother’s visitor had to ask someone in the hallway to check on the resident after waiting a long time for a response to the call light; the person who checked stated the resident was dry, but the visitor could smell urine and knew this was not accurate. The resident was later taken to the bathroom by others, including a physical therapist, who stated that because the resident was not bearing weight on her legs, they would not be able to continue taking her to the bathroom. The daughter expressed concern that her mother would be incontinent of urine and stool and remain so for hours before being changed, and that even when calling out for help, it took an extended time for assistance to arrive, if at all. She also stated that CNAs were supposed to check residents every two hours but did not, and that she had observed this pattern on each of her visits. During the survey, a state surveyor activated a resident’s call light and observed that it remained active for 16 minutes and 15 seconds before resetting, requiring re-activation by the resident. The surveyor activated the call light at 2:22 P.M., again at 2:33 P.M. while it was still red, and again at 2:38 P.M. after the red light disappeared, with staff not answering until 2:40 P.M. The CNA who responded confirmed she was alerted via walkie talkie but could not state when the call light was first activated. The maintenance director and assistant verified through the call system computer that the call light had been on for 16 minutes and 15 seconds before resetting and then was activated again, confirming the system automatically resets after that time. An anonymous staff member also confirmed that call lights were not answered timely and that residents had voiced concerns. The facility’s call light policy stated that call lights would be silent only after residents’ needs were met, which was not followed in these instances.
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