Deficiency in Call Bell System Management
Penalty
Summary
The facility failed to ensure a routine process for the functioning and timely response to call bell systems during weekends on the 1st and 2nd nursing floors. The facility's policy, revised on June 1, 2021, mandates that patients have a call light or alternative communication device within reach at all times when unattended, and that staff respond promptly. However, interviews with two residents on the second floor revealed complaints about delayed responses from nursing staff when using call bells. Additionally, the facility's grievance log for November and December 2024 documented concerns about long wait times and staff being on their phones while call bells were active. Call bell audits for these months showed that audits were conducted primarily during the day shift, with only two during the evening shift, and none on weekends.
Plan Of Correction
Resident call system works properly, and call bells are answered timely. Initial whole house audit of the resident's call bell system (bathroom and bedside) will be completed to ensure function by the Maintenance Director/designee. A Center-wide Walk through was completed and all activated call bells were being addressed timely. NHA/designee will educate Center employees on timely response to call bells. Weekly Weekend audits x 4 then monthly x 2 are to be conducted at random locations to ensure the call bell system is working. NHA/designee will report all findings to be discussed in QAPI meeting x 3 months.