Inaccessible Call System for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that Resident #30 had access to a call system to request staff assistance, as required by their policy. The call bell for Resident #30 was consistently found out of reach and out of sight, placed on a stationary chair in the corner of the room. This was observed multiple times over several days, and the resident expressed difficulty in calling for help, stating they had to yell for assistance. The resident, who had a history of falls and was at risk for further falls, was observed transferring themselves to the toilet without assistance, indicating a lack of available support due to the inaccessible call system. The facility's policy mandates that call lights be within reach of residents at all times to ensure their safety and ability to communicate needs. Despite this, the call bell for Resident #30 was repeatedly found in an inaccessible location, and staff interviews confirmed that call bells should be within reach. The resident's care plan highlighted the need for supervision with transfers and ambulation, yet the lack of an accessible call system compromised their ability to request necessary assistance, potentially increasing their risk of falls.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident #30 was immediately provided with her call bell, and the call bell has been kept within reach. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. All residents had the potential to be affected by the deficient practice. Unit Managers completed a Full house audit of residents to assure call bells are within reach. No further call bells not within reach were found. The Staff educator/Designee provided reeducation for all staff to place call bell within reach for all residents, while in bedroom. Weekly call bell placement audits will be conducted by Unit Manager/designee and reported to DON. All issues will be corrected immediately. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits. For compliance, any negative findings will result in immediate education. The audit's results will be reported to QAPI monthly meetings. Then quarterly, the frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.