Nonfunctioning Resident Call Buttons: Two residents had call buttons that did not work, and testing showed no light or alarm at the nurse’s station. An LVN later gave each resident a handbell as a temporary replacement, but one resident reported ringing it overnight without response and woke up with a soaked brief. Staff interviews showed the handbells were not clearly communicated to all aides, and the MAINTD said the call system problem was related to cords wrapped around bed frames causing a short.
A facility failed to keep working call systems accessible in two shared restroom areas. In one restroom, the call light by the toilet had no pull string attached, and in another, the call light string could not be reached from the shower. Staff, including an RN, LVN, CNA, DON, and MTD, acknowledged that residents needed call lights within reach from the toilet, shower, and floor, and maintenance logs did not document the missing cords.
Nonfunctioning Resident Call Light System: A resident with Alzheimer’s disease and significant cognitive impairment was observed in bed with a call button on the tray table that was not attached to anything. When the resident pressed it, the device did not alert the nurses station. A CNA/med aide and MTS confirmed the call button was not working, and the ADM stated staff had not been given routine guidance for checking call lights unless a resident reported a problem.
A facility failed to keep call lights within reach for four residents who needed staff assistance. One resident with OA, carpal tunnel syndrome, and age-related cognitive decline, one resident with hemiplegia, epilepsy, and cognitive communication deficit, one resident with dementia and cognitive communication deficit, and one resident with hemiplegia and Parkinson's disease were observed in bed with call lights wrapped around the bedframe, hanging off the bed, or on the floor and out of reach. Staff interviews confirmed that call lights are supposed to be placed within residents' reach before leaving the room.
Two residents with significant cognitive impairment and high assistance needs had nonfunctioning call lights in their rooms. One resident reported pressing the call light for repositioning without receiving help, and testing confirmed that the bedside and hallway indicators did not activate in either room. Staff, including an LPN, CNA, EVS Director, DON, and Administrator, acknowledged that residents should have functioning call lights, while records showed no outstanding repair requests and only selected rooms were included in routine call system testing.
The facility failed to maintain a functional call light system with reliable audible notification at the nurses’ station, resulting in delayed staff response to resident requests for assistance. In one instance, a resident repeatedly yelled for help while the call light was illuminated but not audible, and the resident reported waiting a prolonged period before an LVN responded and assisted with a transfer that the resident could not complete due to a malfunctioning bed. An RN acknowledged that call lights often illuminated without sounding, and observations showed multiple call lights active in hallways without corresponding audible alarms or accurate display at the call light notification center, which sometimes showed error or “failed” messages. The Maintenance Director reported the system was obsolete, frequently unplugged, and prone to error messages and continuous beeping, and that he had raised these issues with the former DON. These conditions were inconsistent with the facility’s call light policy requiring prompt response and proper use of the system.
A resident with dementia, Parkinson’s disease, muscle weakness, and a high fall risk was found in bed without a call light within reach, despite being cognitively intact and care-planned to have the call light accessible and to receive prompt assistance. The call light cord was discovered wrapped and stored behind a roommate’s nightstand, and the resident reported not knowing it was there, while the roommate stated they would press their own call light when the resident needed staff. Multiple LVNs, the DOR, DON, and ADM confirmed the resident could use a call light, that all staff were responsible for ensuring call lights were within reach during rounds and room entries, and that facility policy required each resident to have a means to call staff from the bed and other areas, but this was not followed for this resident.
A resident with intact cognition, diabetes, chronic pulmonary edema, and major depressive disorder was found to have a broken call light that remained nonfunctional during repeated observations. Staff saw the broken call light but did not report it, and the resident said she had to yell for help when she needed assistance. Interviews showed the maintenance request was not entered until the Area Maintenance Supervisor demonstrated the process, and the facility lacked a functioning call light policy.
Call Light System Not Working in Available Resident Room: A room marked ready for move-in had a call light issue when the hallway indicator flashed but the nurse call panel did not activate or ring for that room. An LVN could not explain the mismatch, another LVN reported housekeeping had activated the light in the empty room and could not turn it off, and the call light box was observed hanging from the wall with wires exposed. The room was listed as ready for move-in on the bed classification report.
Call Lights Not Kept Within Reach: Survey observations and record review showed that three residents with severe cognitive impairment and significant dependence for ADLs did not have their call lights within reach. One resident with chronic respiratory failure, diabetes, heart failure, and weakness had a call light wound around the bedframe; another resident with dementia had a call light tied to the bedframe and hanging off the bed; and a third resident with acute respiratory failure and a G-tube could not verbally communicate needs and had a call light hanging off the bed and tied to the frame. Care plans for all three directed staff to keep the call light within reach.
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