Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for each resident at their bedside, specifically for a resident who required assistance with transfer and locomotion. This resident, who had a history of traumatic brain injury, anoxic brain injury, and myocardial infarction, was observed on multiple occasions with the tap call bell out of reach. The resident was non-verbal and dependent on staff for mobility, necessitating the call bell to be placed on their knee when out of bed. However, during observations, the call bell was found hanging on the wall or placed on the bed, both out of the resident's reach. Interviews with staff revealed inconsistencies in the placement of the call bell. A nurse manager confirmed that the call bell should be on the resident's knee, while a CNA stated they placed it on the resident's lap or chest, depending on whether the resident was in a wheelchair or bed. Despite these procedures, the call bell was not consistently within reach, as confirmed by the Chief Nursing Officer, who emphasized the importance of ensuring accessibility. The deficiency was identified during a recertification and abbreviated survey, highlighting a lapse in the facility's adherence to ensuring resident safety and communication needs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #39 Resident #39’s tap bell was immediately placed on his knee per the plan of care; no further corrective action was required. The IDCP Team determined that the resident continues to benefit from the use of the tap bell and ensured that this is in the CCP. The Nurse Manager re-educated all unit staff regarding their responsibility to ensure that call bells, including tap bells or other adaptive call bell devices, are within reach of the resident. Licensed staff responsible for administering medications were provided with additional education regarding their responsibility to check if the call bell is within reach when completing medication administration. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who are unable to utilize the facility’s standard call system may be affected by the same practice. The Nurse Managers and Rehabilitation staff will identify any resident who cannot manipulate a standard call bell to determine if the resident would benefit from an adaptive call bell or tap bell. The Nurse Manager will update the plan of care as needed and review the plan of care with the unit staff. The Nurse Manager, licensed nurses and CNAs continue to make rounds and resident observation at various times every shift to monitor residents including their access to their call bell. If a resident is noted not to have their call bell in reach, the situation is corrected by the staff member who identified that the call bell was not accessible. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Chief Nursing Officer reviewed the facility’s policy for Call (NAME) Use, and determined no revisions were necessary. Nurse Managers on all units will re-educate staff regarding their responsibility to ensure that tap bells and other call devices are within reach of the resident while in their rooms. Nurse Managers/Nurse Supervisors/Charge Nurses will conduct routine observations each shift during rounds to ensure residents requiring a tap call bell or adaptive call bell have them in place. Any call bell which is identified to be out of reach will be immediately addressed and responsible staff re-educated as necessary. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with ensuring all call bells including alternative call bells, such as tap bells, are within reach of residents when they are in their rooms. The Nurse Manager/designee will audit a sample of 10 call bells per shift per unit monthly for three months and then quarterly for two quarters, for accessibility and placement as per the plan of care. The sample audit will include residents requiring a tap bell or other adaptive call bell. The Chief Nursing Officer/ designee will report call bell related audit findings monthly to the QAPI Committee for three months and then quarterly for two quarters. The accepted level of compliance is 95%. At the end of the reporting period, the QAPI Committee will determine the need for further auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer