- Date
- 3/14/2025
- Report number
- CALMS - 00085040
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to answer call light in a timely manner
- Result
- Substantiated
- Findings
- Based on observation, interview, and record review, conducted during a site visit on 04/08/25, the facility’s failure to provide a call system that connects resident units to the care staff center or staff pagers was substantiated for 2 of 2 sampled residents (#s 1 and 2). Findings include but are not limited to: Staff 1 stated residents have pull cords and most have pendants that connect to the facility’s call system. Staff have cell phones and use the call system’s application to respond to call lights. Staff 4 stated when the facility’s internet was down, the call system didn’t work. When residents used the call system, an alert displayed on staff’s devices. Residents have tested their call light with Staff 4, and Staff 4 didn’t receive an alert on his/her device. Staff 5 stated when s/he was working, sometimes s/he didn’t receive alerts for the call system on his/her device. Resident 1’s call light was pressed at approximately 1:49 pm. At approximately 2:05 pm, multiple direct care staff members were observed walking past Resident 1’s door without responding to the call light. Staff 5 was asked about active alerts. Staff 5 opened his/her device, and the following alerts were displayed:
-At 2:13 pm, the application displayed a “new alert” approximately 24 minutes prior;
-A “re-alert” approximately 22 minutes prior;
-A “re-alert” approximately 20 minutes prior;
-A “re-alert” approximately 18 minutes prior; and
- “Alert completed” approximately 16 minutes prior for Resident 1’s room.
There was no caregiver observed entering Resident 1’s room to check on him/her during the time the alert was active and when the alert was completed. Resident 2’s call light was pressed at approximately 2:26 pm. At 2:46 pm, no staff member had responded to the call light. Staff 6 was asked about active alerts. Staff 6 opened his/her device and there was no active call listed on the staff’s device. Staff 1 was asked about the alerts for Residents 1 and 2. When Staff 1 reviewed the call light system, no alerts displayed for Residents 1 or 2 for that day. It was determined the facility’s failure to provide a call system that connects resident units to the care staff center or staff pagers was substantiated for Residents 1 and 2. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3 via phone.