Call Bell System Malfunction in Resident Bathroom
Penalty
Summary
The facility failed to ensure that the call bell system in room [ROOM NUMBER] on Unit 1 was functioning properly, which compromised the ability of residents to call for assistance while in the bathroom. During a resident meeting, it was reported that the bathroom call bell, when activated, would flash outside the door, but if the room call bell was pressed simultaneously, it would cancel out the bathroom call light. This malfunction left residents without a means to alert staff for help, as evidenced by one resident being left in the bathroom for up to an hour. Observations confirmed that the bathroom call bell, when pulled, would initially cause a rapid flashing blue light and a beeping sound. However, when the room call bell was activated, the light turned solid blue, and the beeping stopped, indicating a cancellation of the bathroom call. Staff interviews revealed a lack of awareness and understanding of the issue, with some staff unsure of how to identify when a resident needed assistance in the bathroom due to the call light cancellation. The Director of Environmental Services/Maintenance acknowledged the issue, stating that the call bell system was outdated and that no corrections had been attempted despite being aware of the problem for approximately six months. The Director of Nursing was unaware of the call bell failures and emphasized the importance of responding to call bells within three minutes. There was no documented evidence of a work order being submitted to address the malfunctioning call bell system.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In room [ROOM NUMBER] on unit one, bulbs were replaced on the call bell system. The bathroom call light flashes a different color than the room call light. All resident rooms have a call bell system. All rooms will have the call light bulbs modified. All call light bulbs in all rooms will be replaced. The bathroom bulb will flash a different color than the room call light, alerting employees to the difference in location. All employees will be educated on the difference in bulb color and flashing. The Director of Environmental Services will audit the call system monthly to ensure that it is alerting staff appropriately. The audit will be reported quarterly to the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 3/6/2025 Person Responsible for Correction: Director of Environmental Services