Delayed Call Bell Response Times
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner on both the first and second floors, as evidenced by a review of facility records and interviews with staff and residents. The facility's 'Call Bell Response' policy, which was undated, stated that call lights should be responded to promptly to promote a secure atmosphere for residents. However, a call bell response time report from November 1 to November 30, 2024, revealed an average response time of 28.07 minutes for 283 call alarms, with some response times extending up to 111.05 minutes. Interviews with several residents and a visiting family member confirmed concerns about prolonged call bell response times. One resident reported experiencing response times of more than 10 minutes but less than 60 minutes, while another reported waiting 20 minutes or more. Another resident experienced response times ranging from 45 minutes to over 60 minutes, corroborated by a family member who noted a 45-minute wait the previous night. The Nursing Home Administrator confirmed the lengthy response times and stated that response times over 40 minutes are investigated, often finding that staff were assisting other residents at the time.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Based upon the 2567, the facility is unable to determine which residents provided statements to the surveyor. An audit was conducted of the call bell response report for the entire month of November 2024. There was a total of 6,112 events with an average response time of 6.58 mins for all of them. An audit of Incident reports and the Grievance log for November 2024 did not indicate any incidents or complaints about prolonged wait for call bell response and no harm or injury was identified. 2. To prevent this from reoccurring, re-education for Nursing staff on the call bell policy and the importance of properly clearing call bell devices. 3. Ongoing monitoring for compliance, DON/designee will review call bell response time reports daily x 2 weeks than weekly x 2 months and investigate any prolonged wait times to ensure proper staff response to call bells. 4. Results will be presented at QAPI for review and revision.