Nonfunctional Call Light in Resident Room
Summary
A deficiency was identified when a resident's call light was found to be nonfunctional since their admission. The resident, who had a diagnosis of hypertension and a history of falls, required moderate assistance with activities of daily living and had an intact thought process. During an observation and interview, the resident demonstrated that their call light did not activate the visual indicator outside the room, and reported having to rely on their roommate's call light to request assistance. This issue was confirmed by a Licensed Vocational Nurse, who also observed that the call light did not work and acknowledged the importance of a functioning call system for timely response to resident needs. Further review of facility policy indicated that the resident call system is required to remain functional at all times and should be routinely maintained and tested by the maintenance department. The Director of Nursing confirmed the importance of a working call light system for communication between staff and residents, noting that a malfunction could result in staff being unable to meet residents' needs immediately. The deficiency was based on direct observation, resident and staff interviews, and review of facility records and policies.
Penalty
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A resident with dementia, anxiety disorder, chronic respiratory failure, and a documented need for substantial assistance with bed mobility was observed with her call light hanging from the bed rail out of her reach. Three pillows were stacked on the side where the call light cord was located, further preventing her from accessing it. An RN confirmed that the call light was not within the resident’s reach, resulting in a cited deficiency related to the call system.
Surveyors found that multiple residents had non-functional call lights in their bathrooms and bathing areas, with some call lights failing to activate outside the room and others not signaling at the nurses’ station. A DOM and an RN confirmed these failures during testing, and a maintenance staff member reported that malfunctioning call lights were an ongoing issue. Review of work orders showed that these specific call light problems had not been reported, despite facility policy requiring staff to immediately report call system issues and ensure residents have access to a working call system.
The facility failed to maintain a call light system that stayed active until staff responded and to ensure timely responses to resident calls. A resident’s daughter reported that her mother waited an extended time for assistance despite using the call light and that she repeatedly observed CNAs not performing 2-hour checks as expected. In another case, a surveyor tested a resident’s call light and found it automatically reset after about 16 minutes, requiring the resident to reactivate it, with staff not answering until several minutes after the initial activation. Maintenance staff confirmed the automatic reset feature, and a staff member acknowledged that call lights were not answered promptly and that residents had complained, contrary to the facility’s call light policy.
Surveyors found that three residents with dementia, impaired cognition, mobility limitations, and other comorbidities did not have call lights within reach while in bed. In one case, a resident’s call light was attached to a privacy curtain across the room; in another, both call lights in a shared room were attached to the roommate’s bed, leaving the other resident without access. A third resident’s call light was wound up over the actuator box near a recliner and could not be reached from the bed, and the bed controller was on the floor out of reach. These conditions occurred despite a facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff.
Call Light Left Out of Reach: A resident with severe cognitive impairment, vascular dementia, and dependence for toileting and personal hygiene was repeatedly observed lying in bed with the call light on the floor and not within reach. The care plan included keeping the call light within reach, and an RN later confirmed it had been out of reach before placing it on the resident’s bed.
Surveyors found that staff failed to keep call lights within reach for two cognitively impaired, ADL-dependent residents who were care planned as fall risks. In one case, a resident seated in a Broda chair had the call light lying on the floor beside the bed, despite a care plan requiring it to be within reach and a sign to prompt use; a CNA confirmed it was not accessible and noted a loop on the cord intended for the resident’s wrist due to blindness. In another case, a resident lying in bed had the call light positioned behind a refrigerator, also out of reach, which a CNA verified. These observations showed the facility did not follow its own policy requiring call lights to be easily reachable when residents are in bed or confined to a chair.
Call Light Not Left Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a working call system was left within reach for a resident in her room, as required for resident bathrooms and bathing areas and evaluated under environmental concerns. The resident had been admitted with dementia, anxiety disorder, and chronic respiratory failure, and her MDS 3.0 assessment documented that she required substantial assistance from staff for bed mobility. During observation, the resident’s call light was found hanging from the bed rail on the right side of the bed, outside of her reach, with three pillows stacked on that side further preventing her from accessing the call cord. A registered nurse confirmed this observation during interview. This deficiency was cited as non-compliance under Complaint Number 2726820.
Non-Functional Call Lights in Resident Bathrooms and Bathing Areas Not Reported or Repaired
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights in bathrooms and bathing areas were functional and operating as required. During an observation period with the Director of Maintenance (DOM), call lights for four residents were tested and found not to activate outside the rooms. For two of these residents, the call lights did not light up outside the room when tested, and the DOM stated he thought the light bulbs had gone bad. For the other two residents, their call lights did not activate outside the room and also did not ring at the nurses’ station when pressed, which was confirmed by both a Registered Nurse (RN) and the DOM. Further interviews and record reviews showed that these non-functioning call lights had not been reported through the facility’s work order system. A Maintenance Assistant stated that non-working call lights were an ongoing issue and that he was sure some were outstanding. Review of electronic work orders for the relevant period did not show any entries for the rooms where the call lights were found to be non-functional. The facility’s policy on call lights states that staff are educated on proper use of the call system, including ensuring resident access, and that staff will report problems with call lights or the call system immediately to a supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied. This policy was not followed for the four residents identified in the complaint investigation.
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.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident call lights were within reach for multiple residents, contrary to facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff. One resident with dementia, depression, high blood pressure, impaired cognition (BIMS score of 3/15), and a self-care deficit related to language barrier and impaired mobility was observed lying in bed asleep with the bed positioned against the wall while the call light was attached to the privacy curtain across the room, out of the resident’s reach. A RN confirmed that this resident’s call light was attached to the privacy curtain across the room rather than being accessible from the bed. Another resident with Alzheimer’s disease, depression, anxiety, high blood pressure, impaired cognition (BIMS score of 5/15), functional incontinence, impaired communication related to dementia, and impaired mobility requiring staff assistance was observed sleeping in bed with no call light in reach; both call lights in the room were attached to the roommate’s bed. The RN confirmed that this resident’s call light was attached to the roommate’s bed and not within reach. In a separate observation, a third resident’s call light was found wound up over the call light actuator box near the recliner, not reachable from the bed, and the bed controller was on the floor at the foot of the bed, also out of reach. These observations showed that three residents reviewed for call light use did not have accessible call systems as required by facility policy.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident #79’s call system was within reach when the resident was lying in bed. Resident #79 was admitted on 10/03/24 and had diagnoses including vascular dementia, metabolic encephalopathy, and cognitive communication deficit. The MDS assessment indicated severe cognitive impairment. The care plan dated 01/12/26 stated the resident was dependent on staff for toileting and personal hygiene, required substantial assistance with repositioning and transfers, and included interventions to ensure the call light was within reach, encourage use of it for assistance, and provide prompt response to requests for help. During multiple observations on 03/02/26, Resident #79 was seen lying in bed with the call light on the floor by the left side of the bed and not within reach. At one observation, the resident was asking for ice cream while the call light remained out of reach. Later observations again showed the resident resting in bed with the call light on the floor. When the RN entered the room, the RN picked up the call light and placed it on the resident’s bed within reach, and confirmed that the call light had been on the floor and not within the resident’s reach. The facility call light procedure dated 03/05/25 stated call lights will be within reach of the resident when in the resident room.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a call light system that was readily accessible to residents in accordance with its policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. For one resident with Alzheimer’s disease, schizophrenia, and major depressive disorder, the care plan identified a risk for falls and included interventions to ensure the call light was within reach and a sign was in place to remind the resident to use the call light for assistance. The quarterly MDS showed this resident was moderately cognitively impaired and dependent on staff for ADLs. On two separate observations the resident was seated in a Broda chair next to the bed while the call light was found on the floor beside the bed, not within reach. A CNA confirmed the call light was not accessible and explained that a loop was placed around the call light cord to go around the resident’s wrist because the resident was blind. A second resident, admitted with dementia, chronic kidney disease, and diabetes mellitus, also had a care plan identifying fall risk with an intervention to ensure the call light was within reach. The quarterly MDS indicated this resident was severely cognitively impaired and dependent on staff for ADLs. During observation, this resident was lying in bed while the call light was located behind the refrigerator, out of the resident’s reach. A CNA verified that the call light was not accessible to the resident. These findings were identified during the course of a complaint investigation and showed that, for two of three residents reviewed for call light accessibility, the facility did not ensure call lights were positioned so residents could use them as required by facility policy and care plan interventions.
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