Delayed Call Bell Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in responding to call bells in a timely manner. Resident 19 reported that when she rings her call bell, staff would come in and say they would return, but they never did. This indicates a lack of follow-through in addressing her needs. Additionally, Resident 52, who was assessed as cognitively intact and requiring extensive assistance for toileting, experienced a significant delay in response to her call bell. On December 3, 2024, Resident 52's call bell was not answered for 32 minutes, and when a nurse aide finally entered her room, the aide left immediately without providing the necessary assistance. Resident 52, who has a diagnosis of irritable bowel syndrome and had not had a bowel movement for three days, required a bedpan to move her bowels. Despite this urgent need, the nurse aide prioritized collecting breakfast trays over attending to Resident 52's call for help. The call bell was answered a second time only after 35 minutes from the initial call. The facility's administration acknowledged these findings, which highlight the deficiency in nursing services as per the relevant state codes.
Plan Of Correction
1. Resident 52 call bell answered at the time of need, Resident 19 made sure all needs are met. 2. DON/Designee will do a random audit of residents to make sure that call bells are being answered timely to see if any other residents affected. 3. DON/Designee will educate nursing staff on 483.35(a), and policy named call bells. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure call bells are being answered timely and all needs have been met of the resident. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.