Resident Call System Deficiency
Penalty
Summary
The facility failed to ensure that a call device was accessible to a resident, identified as Resident R6, who was observed during a lunch meal service. Resident R6, who has a medical diagnosis of hemiplegia and hemiparesis affecting the left non-dominant side, was unable to reach the call bell placed on the left side of the bed due to their condition. This observation was made while Resident R6 was in bed with a lunch tray on the bedside table, and the resident was seen coughing continuously while consuming the meal and unable to verbalize the need for assistance. Interviews with facility staff confirmed the deficiency. A licensed nurse, Employee El, confirmed that Resident R6 was unable to use her left upper extremity due to hemiplegia and hemiparesis. Additionally, the facility's Director of Nursing, Employee E3, confirmed that the call bell for Resident R6 should have been placed on the right side of the bed, which was not done, leading to the resident's inability to call for assistance.
Plan Of Correction
1) Resident's care plan was updated to have call bell light on her stronger side. 2) Nursing will identify residents perceived to have a weakness or deficit on one side of the body. These residents will be referred to therapy for recommendations of care r/t the weak side regarding call bell placement and the resident's ability to use the call bell. 3) Nursing will be educated to ensure that residents call bell light is within reach of the resident and that resident can access and use. 4) Call bell audit will be completed by each unit manager weekly x 4 and monthly x 2 to ensure that call bells are always within reach of the residents and able to be accessed. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.