Complaint Investigation Report

Allegation: Facility signal system did not produce an auditory signal loud enough to summon staff.

It is alleged Resident R1 was not feeling well in the middle of the night and pressed the medical alert button, but nobody came. R1 then called the front desk, and nobody answered the phone.

During an interview with R1’s Responsible Party (W1) stated facility staff left them a voicemail stating the battery was low in R1’s pendant. Additionally, W1 stated when they brought R1 back from the hospital the following afternoon the facility’s phone system was still down. During interviews with Staff (S1 and S2), two (2) out of two (2) stated there was an issue with the phones on December 12, 2023, and that the phone system has gone down in the past. S1 stated there has been a new procedure implemented for when the phone system goes down and for the medical alert pendant to inform them when batteries are low on a resident’s pendant. During interviews with Residents (R1-R6) two (2) out of six (6) stated there has been times when they press their pendant for assistance and had to wait an extended period of time before a caregiver arrived and they received care. R6 stated there was a time they had to wait three (3) hours before assistance came. R1 stated that having to wait for assistance commonly occurs in the evenings and nights. During interviews with staff (S1-S7) seven (7) out of seven (7) stated they receive training annually regarding the medical alert pendants and had a training regarding the new procedures implemented regarding low batteries in pendants and the telephones when down.