Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call bell was within reach for a resident who was capable of using it and required assistance. The resident, who had a history of a stroke affecting his left side and needed maximum to total assistance for activities of daily living, was observed in two separate instances where the call bell was not accessible. During an interview and observation, the call bell was found looped over the lowest part of the mobility bar with the button on the floor, making it unreachable for the resident. In another observation, the resident was sitting in an adaptive chair with the call bell placed on the bed and out of reach. Despite the resident's request for the call bell, the CNA did not immediately place it within reach, delaying the resident's ability to call for help.
Plan Of Correction
F558 Reasonable accommodation of needs Resident #42 call bell out of reach Corrective actions What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #42 call light was placed within reach during survey. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. DON/designee conducted an initial audit of all residents' call lights conducted to identify any other affected residents affected by deficient practice on 2/13/25. There were no other affected residents. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Weekly audits of all rooms will be conducted by DON or designee to ensure compliance with appropriate call bell placement X 4 weeks, then bi-weekly x 2 weeks then monthly X 1 then PRN. Results will be reviewed for quality by DON or designee. Guardian angels will round in their assigned times weekly x 4 weeks, then bi-weekly x 2 weeks then with their scheduled routine room rounds for appropriate call bell placement. All staff will be reeducated to ensure the call bells are secured within easy reach of residents after provision of care and services before leaving residents' rooms. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. DON will present the results of quality review in QAPI for oversight and revision if needed. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.