Deficiency in Call Bell System Due to Lack of Pager Use
Penalty
Summary
The facility failed to ensure that the call bell system was in full working order across six units, namely Lilac Lane, Vineyard, Rosewood, Riverview, Hilltop, and Grandview. The deficiency was identified through a review of facility policy, documents, staff interviews, and observations. The facility had an exemption dated 10/3/19, which required the use of pagers by staff to notify them directly of an activated call bell. However, it was found that staff were not in possession of pagers, and the system relied solely on kiosks placed in hallways and at nurses' stations to indicate when a call bell was activated. Interviews with various staff members, including maintenance employees, occupational therapists, registered nurses, and nurse aides, revealed a lack of awareness and use of the pager system. Maintenance Employee E3 and Occupational Therapist Employee E6 confirmed the presence of kiosks but were unaware of any pager system. Registered Nurse Employee E5 mentioned that pagers were used in the past but were no longer in use, and expressed that pagers would be helpful for responding to call bells. Other staff members, including Nurse Aide Employees E7, E10, and E11, also indicated that the system relied on kiosks and that pagers were not currently in use. The Nursing Home Administrator (NHA) confirmed that the facility was not using pagers and was unaware of the pager requirement in the exemption. The NHA was observed distributing gold ring bells to residents as a backup system, indicating a lack of confidence in the current call bell system. The deficiency highlights the facility's failure to comply with the exemption requirements, resulting in a call bell system that does not adequately notify staff of resident 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.