Deficiency in Call Bell System Management
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program specifically related to the call bell system pager use. The facility's policy on 'Call Bells: Accessibility and Timely Response' indicates that call bells should directly relay to a staff member or a centralized location to ensure an appropriate response. However, the facility's documentation and staff interviews revealed that the call bell system was not functioning as intended. The system was supposed to alert staff through kiosks and pagers, but the pagers were not being used effectively, and staff were not adequately informed or trained on their use. Interviews with various staff members, including maintenance employees, occupational therapists, registered nurses, and nurse aides, highlighted inconsistencies and confusion regarding the call bell system. Many staff members were unaware of the pager system or confirmed that it was not in use. Some staff mentioned that pagers were available but not functioning correctly, leading to reliance on kiosks in hallways and nursing stations to identify activated call bells. This situation resulted in staff having to physically check kiosks to determine which resident required assistance, which was not in line with the facility's policy or the intended design of the call bell system. The Nursing Home Administrator acknowledged the lack of pager use and expressed a desire to implement them. However, it was confirmed that the call bell pager system had not been included in the facility's QAPI meetings, indicating a failure to address this issue through the QAPI program. This oversight contributed to the deficiency, as the facility did not effectively utilize its QAPI program to focus on outcomes related to the call bell system, impacting the timely response to residents' needs.
Plan Of Correction
1. Call bell pagers are in place for each unit and nursing employee. Nursing staff are to sign out the pagers at the start of their shift and return them when their shift is completed. The pagers work in conjunction with the call bell kiosks on the units. Residents will continue to use the current call system by utilizing the call bell in their room. 2. Facility staff will be educated on the pager system. This will be conducted by the DON or designee. 3. The functionality and response time of the pagers will be tested by the maintenance director/DON or designee daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 4. Resident interviews will be conducted on call bell response time by social services director or designee. 10% of residents will be audited daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 5. Monthly QAPI meetings are in place and the call bell system is placed on a performance improvement plan for monitoring including audits and resident interviews. 6. Results of PIP will be submitted and reviewed through internal QA process.