Deficient Resident Call System on First Floor
Penalty
Summary
The facility failed to provide a functioning resident call system for four out of six residents on the First Floor nursing unit. Observations revealed that the call lights in resident rooms were lit but did not produce an audible alert, preventing staff from responding to residents' needs. Resident 1, who was alert and oriented with diagnoses including heart disease and diabetes, reported that his call bell did not work, and staff did not respond due to the lack of sound. Similarly, Resident 5, also alert and oriented with diagnoses including adult failure to thrive and diabetes, confirmed that his call bell was non-functional. Resident 6, with major depressive disorder and anxiety, stated that the call bell light remained on continuously without sound, indicating it had not worked for some time. Additionally, Resident 2, who was alert and oriented with a diagnosis of sepsis, was found with an unplugged call bell that did not function even when plugged in. The Director of Nursing acknowledged that the call bell system on the First Floor had been inconsistently operational for a while. These deficiencies highlight a significant lapse in the facility's ability to ensure residents can effectively communicate their need for assistance, as required by regulations.
Plan Of Correction
1. Facility issued hand bells to Residents 1, 2, 5, and 6. 2. Facility will conduct a whole house audit on the call bell system and provide additional hand bells or fix the issues. 3. Facility has contacted an electrical company to assess repairs needed for the call bell system. Once the facility receives the service report, it will make a plan to address areas of the system that are in need of parts for repairs or replacement. Assessment was completed and awaiting to locate and to order necessary parts to repair or replace; unsure whether parts will be found by POC date. 4. Nursing Staff, IDT, and maintenance team will be re-educated on the need to provide a working call bell system. Re-education will include steps to take in the event a call bell is determined not to work. 5. NHA/Designee will conduct audits of the call bell system to ensure the system is maintained and functioning properly. Audits will be conducted 3 x week for 2 weeks, then weekly x 4. All results will be reported to the QAPI Committee.