Failure to Ensure Accessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a functioning call bell was accessible for a resident, identified as Resident 14, who was part of a sample of 25 residents. Resident 14 had medical conditions including heart failure, muscle weakness, and chronic respiratory failure, and required assistance from staff for activities of daily living. The resident's care plan included an intervention for staff to ensure that a functioning call bell system was within reach and that the resident should be encouraged to use it. However, on January 28, 2025, the resident was observed in his room, soiled and needing to be changed, and reported that his call bell did not work. When the resident pressed the call bell button, the light outside his room, which was supposed to alert staff, did not activate. Further observations on January 29, 2025, revealed that the resident attempted to reach his call bell to request ice cream, but the call bell button was hanging below the bed and out of reach. The call bell remained in the same inaccessible position during a subsequent observation. In an interview on January 31, 2025, the facility's Administrator acknowledged that the resident's call bell light was not functioning properly and required repair. This deficiency indicates a failure to accommodate the resident's needs and preferences as outlined in the care plan, potentially compromising the resident's ability to communicate needs effectively.
Plan Of Correction
Rounds were made by Assistant Director of Nursing and EVS staff to ensure resident's call bells were functioning and within reach. Resident 14's call bell was replaced and functioning appropriately and placed within reach. Nursing, Community Life, Therapy, and Housekeeping staff will be re-inserviced by Director of Nursing / Designee on ensuring residents have their call bell within reach. Random audits will be completed by Director of Nursing / Designee on ensuring residents have their call bells within reach and that they are appropriately functioning weekly x4, monthly x2. Results of audits will be reviewed by the facility QAA Committee for further recommendations and/or follow-up.