Call Bell System Volume Deficiency
Penalty
Summary
The facility failed to ensure that the volume on the resident call bell system at the nurse's station on floor 3 was set to a level that could be heard. This deficiency was identified during observations and interviews conducted on 12/19/2024. At 11:50 AM, a test of the call bell from a resident's room revealed no audible notification of activation. A similar observation was made at 11:55 AM from another resident's room, where again, no audible notification was heard. Nursing staff later informed the surveyor that the volume on the call bell system had been turned all the way down, which they subsequently corrected. The Director of Maintenance confirmed these observations during the survey.
Plan Of Correction
1. The call bell volume at the 3rd floor nurses station was immediately restored to an audible level. Rooms 315 and 316 were tested and confirmed operational with both visual and auditory alerts. All nursing staff were notified of the deficiency and instructed on the importance of maintaining appropriate call bell volume levels. A reminder was issued emphasizing that adjusting the call bell volume downwards is unacceptable on 12/20/24. 2. All residents have the potential to be affected by this practice. All 3 call bell systems throughout the facility were checked to ensure appropriate volume levels and functionality. 3. A facility policy and procedure on call bell system management will be created by 1/15/25 to include: - Specific instructions regarding appropriate call bell volume levels. - A prohibition against turning down or muting call bell volumes. - A defined requirement for regular checks of call bell system functionality, including volume levels. - A process for documenting call bell system checks. - Clear instructions on how to troubleshoot call bell system issues. All nursing and maintenance staff will be re-educated on the new policy and procedure by 1/24/25 by the clinical nurse educator. 4. Daily audits of call bell system functionality and volume levels in all resident rooms and common areas will be completed by the maintenance department for 4 weeks and then monthly ongoing. Results will be tracked and reported to the Quality Assurance Committee quarterly and to the QAPI Committee monthly.