Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, which was identified for two residents. Resident #8, who has moderately impaired cognition and requires maximum assistance for Activities of Daily Living (ADL) care, was observed multiple times seated in a wheelchair with the call bell affixed to the right enabler, out of reach. Despite the care plan intervention to encourage the resident to use the bell for assistance, the call bell was consistently placed out of reach by the Certified Nursing Assistants (CNAs) responsible for the resident's care. Resident #11, who has severe cognitive impairment and is dependent on staff for ADL care, was found in bed with the call bell on the floor under the bed, making it inaccessible. The resident's care plan also included an intervention to encourage the use of the call bell for assistance. The facility's policy requires that residents have a means to call staff for assistance, but this was not adhered to, as confirmed by the CNAs and the Licensed Nursing Home Administrator.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #11 call bell was placed within reach immediately. The unit managers ensured the call light was within reach daily. Plan of care reviewed. "Resident #8 call bell was placed within reach immediately. Plan of care reviewed. "Education was conducted with assigned CNAs by Director of Nursing regarding the placement of call bell after care. "Education was completed with all nursing staff regarding the placement of the call bell. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by this deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Ongoing education will be provided to all nursing staff by the Director of Nursing regarding the placement of call bells after care. "Call bell policy reviewed, and education provided to all nursing staff by Director of Nursing. "The Director of Nursing or designee will check the placement of call bells daily at the beginning of each shift. 4. Monitoring corrective actions: "The Director of Nursing or designee will audit 5 call bells placement weekly x 3 months and then monthly x 3 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.