Failure to Provide Accessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that call bells were accessible for a resident, identified as Resident 13, who had significant physical limitations. Resident 13 had diagnoses including hemiplegia, hemiparesis, contracture of muscle, and muscle weakness, which required extensive assistance from staff for mobility and activities of daily living. The care plan for Resident 13 included an intervention for staff to provide a handbell to call for assistance due to the resident's self-care deficit and risk for behavioral symptoms. On April 8, 2025, Resident 13 was observed in bed without a handbell at multiple times throughout the day. During an interview, Resident 13 stated that she could not find her handbell. The Director of Nursing confirmed that the handbell should have been provided to Resident 13 to call for assistance, indicating a failure to accommodate the resident's needs as outlined in the care plan.
Plan Of Correction
Part 1. Resident #13 was provided with a hand bell as care planned. Part 2. Residents with/without psychiatric diagnosis were audited to ensure care planned interventions for a call light or alternative communication device is in place at all times. Facility audit completed to ensure each resident has a call bell clip to secure the call bell within easy access of the resident. Part 3. Facility staff education on ensuring residents with/without psychiatric dx are provided with a call light or alternative communication devices as care planned and that call bells are accessible. Part 4. Residents with/without a psychiatric dx will be audited to ensure care planned interventions for call bells are in place. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.