Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call bells were within reach for one of six residents, specifically Resident R4. According to the facility's policy on call lights, it is required that residents have a means of communicating with staff, and a call system is installed in each resident room. Resident R4, who was admitted to the facility on December 15, 2023, had a care plan indicating a risk for falls due to poor safety awareness, with a specific instruction to keep the call light within reach at all times. On January 12, 2025, Resident R4 was observed in her wheelchair, slouched and in distress, crying out due to back pain. During this observation, it was confirmed by Nurse Aide, Employee E11, that the call bell was not within reach of Resident R4. The Nursing Home Administrator also confirmed the facility's failure to ensure the call bell was accessible for Resident R4, which is a violation of the resident's rights and the facility's policies.
Plan Of Correction
Resident #4 was immediately provided call bell. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee completed a whole house sweep to ensure residents call bells were within reach. There were no negative findings. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on ensuring that a resident's call bell is within reach. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure that call bell is within reach. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.