Failure to Maintain Operational Call Light System for Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was operational for a resident’s room and bathroom/bathing area, as required by its policy and resident care needs. During observation, the resident identified as #94 activated their call light, but the corridor light above the door did not illuminate or sound, and the call light system monitor at the nurses’ station did not display the room number. The resident reported that the call light had not been working, stating that maintenance had replaced the cord but the system still did not function. The resident’s baseline care plan indicated a need for stand-by assistance with ambulation, yet the resident had no functioning call light or bell available at the time of the initial observation. Further observations and interviews showed that the issue with nonfunctioning call lights was ongoing and not documented in the maintenance logbook. On review of the maintenance logbook, there were no entries indicating call lights needing repair until a CNA documented that the call light in this resident’s room and another room were not working. Staff interviews revealed that the call light system’s lights and monitors did not always work, and a CNA reported experiencing issues with call lights not working almost daily. The DON stated that there was no prior written documentation of call light problems because staff had been reporting them verbally rather than through the logbook, despite the facility’s policy requiring defective call lights to be reported to maintenance or administration to be addressed promptly.
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