Resident Left Without Functioning Call Bell After RN Unplugs System
Summary
The deficiency involves the facility’s failure to ensure a fully functioning and accessible call bell system for a cognitively intact resident, resulting in the resident being without an active call system in the room and bathroom/bathing area for an extended period. The resident had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx, and was assessed as cognitively intact with a BIMS score of 15. Facility policy required that call lights be plugged in and functioning at all times and that residents unable to use call lights be checked frequently. Despite this policy, the resident’s call bell was disconnected from the wall and left inaccessible on the floor, leaving the resident unable to summon assistance. According to facility documentation and witness statements, during a night shift an RN attempted to address a problem with the television sound that was controlled through the call system remote. The resident requested that the TV sound be turned off, and when the RN could not silence the sound using the available controls, the RN removed the call system cord from the wall to stop the noise. The RN acknowledged that this action disconnected the call system and that no alternative call method (such as a hand bell or backup cord) was provided to the resident. The resident later reported that the call bell was left on the floor and was not accessible, and that she experienced an episode of emesis and was unable to call for assistance because the call bell had been disconnected. Additional staff statements indicated that other staff were aware the call light was not working and did not ensure that the resident had an alternative means to call for help. A nurse aide reported being told by the RN that the call light was not working and that she did not know how to fix it. Another undated/unsigned witness statement described a staff member seeing the call light going off at 2 a.m., being told by the assigned nurse that the light had been broken that shift and that it was fine with no need to enter the room, and therefore not checking on the resident. Facility documentation also showed a gap in the resident’s MAR documentation between 1:25 a.m. and 4:00 a.m. The Nursing Home Administrator later confirmed that the facility failed to provide a fully functioning call bell system for this resident, which was determined to be an immediate jeopardy situation.
Removal Plan
- Tested Resident R1's call bell to ensure proper functioning and verified the resident had access to a functioning call system positioned appropriately to meet the resident's needs.
- Completed an assessment of Resident R1 to ensure no adverse outcomes occurred as a result of the call bell being unplugged; no injuries found.
- Educated staff from all departments on call bell accessibility and what to do if the call bell stops working.
- Inspected and tested all resident rooms and common areas with call bell access for functionality and accessibility; no issues identified.
- Had an outside vendor examine the nurse call system and test all activation points; all found in good working condition.
- Conducted a root cause analysis regarding the call bell issue and performed an audit of the call bell system in all resident rooms and common areas where residents may initiate a call.
- Implemented a preventative maintenance schedule for ongoing monitoring of the call bell system.
- Re-educated staff on daily visual checks of call bell accessibility and reporting procedures for any identified functionality issues.
- Implemented Maintenance Director/designee audits of call bell functionality and maintained documentation, reviewed results at QAPI, and corrected and reported any deficiencies immediately.
- Updated the TELS maintenance tracking system to include conducting a test of the nurse call system.
- Completed immediate corrective action for Resident R1 and completed facility-wide call bell testing, with ongoing preventative maintenance and monitoring to continue.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that a cognitively impaired, functionally dependent resident with aphasia did not have a working bedside call light on multiple observations, and the alternative bell was placed out of reach on top of a mini refrigerator. The resident’s care plan and MDS documented extensive ADL assistance needs and fall/safety precautions. The Maintenance Director reported being unaware of the inoperable call light despite an equipment rounding program, while the Administrator described bedside bells as a matter of resident preference rather than a substitute for a nonfunctional call light. A CNA stated that staff are expected to keep call lights within reach and report malfunctions, and facility policy required fully functional, accessible call devices in resident rooms and bathrooms with regular testing, which was not followed in this case.
Call Light System Not Functioning in 500 Hall: A facility failed to ensure the call light system worked in the 500 hall bathroom and bathing area. Repeated observations showed the panel light stayed on while the light above the room did not illuminate, and one room's bed B call light did not light at either the door or the panel. The maintenance log also showed repeated call light issues, and the MDS stated the panel was sometimes reset when the error occurred.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
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.
A resident with Alzheimer’s disease, severe cognitive impairment (low BIMS score), and communication difficulties was care planned for supervision with toileting and partial assistance with bathing, yet was observed ambulating independently to a shared bathroom where the emergency pull-cord system was not functioning. Surveyors found that pulling the bathroom emergency cord did not activate lights or an alert at the nurse’s station, and a CNA was unaware whether the cord signaled at the station. This confirmed that a working emergency call system was not available in the bathroom and bathing area used by the resident.
The facility failed to maintain a functional call system for three residents on one hallway, resulting in non‑working call lights in bedrooms and bathrooms and, in one case, the complete absence of a call light. One resident, care planned to use a call light, instead received a drum she could not effectively use, requiring her to yell or wait for staff checks. Another resident with a traumatic brain injury and convulsions reported having no call light or alternative device and having to walk to the nurses’ station for help. A third resident with diabetes and anxiety also reported a non‑functioning call light and no alternative call system, stating he had to search for staff. The Administrator and a CNA confirmed the south hallway call lights had been inoperative for an extended period, and the acting Maintenance Director acknowledged awareness of the problem and the importance of a working call system.
Nonfunctioning Call Light and Inaccessible Bell for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the resident call system when a cognitively impaired resident with aphasia and significant self-care deficits did not have a functioning bedside call light on three separate observations. On each observation, the call light was present near the resident’s bed but was not operational, and the resident’s bell was placed on top of a mini refrigerator beside the bed rather than within reach. The resident’s care plan documented self-care deficits and the need for assistance with most ADLs, including fall and safety precautions, and the MDS showed total dependence for toileting and lower body dressing, setup assistance for eating, partial assistance for upper body dressing, and substantial assistance for showering and position changes. Interviews revealed that the Maintenance Director was unaware that the resident’s call light was not operating, despite a facility program in which department heads are assigned to check resident equipment. The Administrator stated that bedside bells were considered a resident preference and that residents could choose to use either the bell or the call light, but not because the call light was nonfunctional. A CNA reported that staff are expected to ensure call lights are within reach and to report nonfunctioning call lights immediately for repair. The facility’s policy required each resident room to have fully functional bedside, toilet, and shower call devices within reach of residents, with systems tested upon installation, monthly, and after maintenance, and accessible from beds, chairs, and bathroom floors, which was not met for this resident.
Call Light System Not Functioning in 500 Hall
Penalty
Summary
The facility failed to ensure the call light system was functioning in the 500 hall bathroom and bathing area. On 05/03/2026, 05/04/2026, and twice on 05/07/2026, observations showed the call light panel in the 500 hall with a room light lit while the call light above the room was not lit. The maintenance log for the 500 hall also documented call light issues on 03/03/2026, 03/06/2026, 04/10/2026, and 05/03/2026 for call lights not turning off. During an observation on 05/07/2026, the call light for room [ROOM NUMBER] bed B did not light above the door or at the call panel. In interview, the Maintenance Director stated the system was checked through periodic audits and review of the maintenance binder, and that the panel was reset when the error occurred. The Administrator stated the light on the call light panel should turn off when the light at the door was turned off, and that observations of them not turning off did not meet expectations.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
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 Bathroom Emergency Call System for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional emergency call system in a resident bathroom and bathing area used by a cognitively impaired resident. Resident #16, who has Type 2 diabetes without complications and Alzheimer’s disease, was assessed on a recent quarterly MDS as having severely impaired cognitive abilities, with a BIMS score of 5/15. The resident’s care plan identified communication problems related to dementia, a primary language of Spanish, and the need for various communication supports and monitoring of her ability to express needs and discomfort. Functionally, the resident required supervision or touching assistance for toileting hygiene and partial-to-moderate assistance with showering/bathing, but was observed during the survey to ambulate independently to the shared bathroom. On an initial bathroom tour on 4/21/26, surveyors observed that the emergency pull alarm in the bathroom shared by specified rooms on Unit 1 appeared non-functional, as it would not light up or be heard at the nurse’s station. This same bathroom was used by Resident #16, who was repeatedly observed ambulating independently to this restroom despite the non-operable emergency call system. On 4/24/26, the emergency pull cord was tested again and, when pulled, did not send an alert to the call enunciator at the nurse’s station. When asked, CNA #3 stated he was not aware whether the emergency pull-cord alarm sent an alert while at the nurse’s station. These observations and staff interviews confirmed that a working emergency call system was not available in the bathroom and bathing area used by Resident #16.
Failure to Maintain Functional Call System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system in resident rooms, bathrooms, and bathing areas for three residents on the south hallway. One resident’s admission record showed she was elderly and care planned to have her call light within reach and to be encouraged to use it for assistance. On observation, her bed and bathroom call lights were not working, and she confirmed this, stating staff had given her a drum to signal for help. She reported she was unable to use the drum effectively, and when she attempted to use it, no audible sound could be heard at her door. She stated that when she needed help, she had to yell or wait for staff to check on her. Her daughter‑in‑law confirmed that the resident was not physically capable of making a loud sound with the drum and that the call light system had not worked since admission. A second resident, with diagnoses including traumatic brain injury and convulsions, was observed in bed with no call light present in the room and a non‑functioning call light in the bathroom. This resident stated she did not have a call light and had to walk to the nurses’ desk to find staff when she needed help, and that no alternative call system such as a noise maker had been provided. A third resident, diagnosed with diabetes and anxiety, reported his call light was not working and that staff had not provided an alternative call system; he stated he had to look for staff when he needed assistance, and no noise maker was observed in his room. The Administrator stated the call light system on the south hallway had not been working for about two weeks. A CNA reported that call lights on the south hallway were not working and that the facility had provided drums as noise makers, while the acting Maintenance Director stated he became aware of the call light system problem the previous week and acknowledged the importance of a working call system so residents can contact staff.
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