A resident reported to a surveyor that the call system in their room was not working after pressing the call button and receiving no response. The surveyor observed that pressing the call button did not activate the call light above the door or the call station at the nurses’ station. An LPN confirmed that the system should provide visual hallway lights, an audible alert, and display the room number at the call station when used, but testing showed the call system in that room was not functioning properly.
Surveyors identified that two residents did not have accessible call light cords in their room, as the cords were found tied and curled on the floor against the wall, despite both residents being alert and ambulatory. In a separate case, a resident reported intermittent problems with a call light that, when tested by the resident, a GNA, and later the NHA, failed to illuminate in the room or hallway on two separate occasions, with staff attributing the issue to a loose wall adapter.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
Inaccessible Bathroom Call Lights: Surveyors observed that two residents had bathroom call light issues on a station 2 unit, including one shared bathroom with a pull cord that was too short and another with no pull cord attached to the call light panel. The MDS stated resident bathrooms should have accessible call lights, and the residents were later observed with accessible pull cords.
Missing Bathroom Call Light Pull Cords: Surveyors observed wall-mounted call light devices in 5 resident bathrooms without accessible pull cords on the [NAME] Ground unit. The LNHA and VP of Facility Services/Maintenance were informed, and the VP stated there were issues with the durability of the pull cords.
Call System at Nurses' Station #3 Was Not Functioning Properly. The facility failed to ensure the resident call system was working properly at one nurses' station, where the panel continuously beeped every few seconds even when no resident calls were active and no room numbers appeared on the screen. RN staff stated the issue had been ongoing and maintenance had already looked at it, while the Maintenance Director later confirmed the abnormal beeping and noted other stations did not have the same problem.
A resident who was totally dependent for all care and bed mobility, with contractures to the RUE and right-sided paralysis, had a call bell found out of reach and entangled on the headboard during repeated observations. Surveyors also found 1 of 3 shower bays in a unit shower room without an adequately long call device activation cord, showing that call devices were not accessible in the resident room and bathing area.
Call Bell Not Accessible and Shower Area Lacked Call Device: A resident's soft touch call bell was observed on the floor on multiple occasions during care, and a GNA and LPN noted it had likely fallen out of reach. During an environmental tour, the shower facility on Station 1 was also found without a call device system.
Call Bell Not Accessible and Delayed Staff Response A resident was observed near the edge of the bed with the call bell cord partially disconnected from the wall outlet and out of reach while asking for assistance. The resident reported that delayed staff response to call light activation was not unusual and said staff had taken up to an hour to respond. After the surveyor reconnected the call bell and activated the pendant call button, no staff responded for about 8 minutes.
Surveyors found that the facility failed to ensure a functioning call bell system on two nursing units, where call lights above resident rooms were illuminated but no audible alerts were heard by staff. On one unit, the call bell panel behind the nurse’s station had tape covering the enunciator speaker and was set to a low tone that was not audible to staff or residents. On the other unit, an illuminated call light corresponded with a panel that had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance reported being unaware of these issues until informed by surveyors, and the administrator and DON were notified of the nonfunctioning systems during the survey.
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