Delayed Call Bell Response Affects Resident Care
Penalty
Summary
Phoebe Berks Health Care Center was found to be non-compliant with certain requirements of 42 CFR Part 483, Subpart B, and the 28 Pa. Code during a series of surveys conducted on May 1, 2025. The facility failed to uphold resident rights by not responding to call bells in a timely manner, which is essential for providing care and services that respect each resident's dignity and preferences. This deficiency affected seven out of 18 sampled residents, who experienced significant delays in receiving assistance for their activities of daily living. The clinical records of the affected residents revealed various medical conditions that necessitated timely assistance. For instance, Resident 45 had radiculopathy and muscle weakness, requiring help with toileting and dressing. Similarly, Resident 54, who had congestive heart failure and late-onset Alzheimer's disease, needed extensive assistance for transfers and daily activities. Other residents, such as Resident 56 with post-polio syndrome and Resident 73 with Parkinson's disease, also required significant support from staff, which was delayed due to the untimely response to call bells. Interviews with the residents and a review of the facility's electronic call bell logs confirmed the delays. Residents reported waiting 30 minutes or more for assistance, with specific instances of prolonged waits documented in the facility's Device Activity Report. For example, Resident 77 waited 168 minutes on one occasion, and Resident 54 waited 91 minutes on another. The facility's administrator acknowledged these delays, which exceeded the expected response time of 15 minutes, confirming the deficiency in meeting the required standards for resident care and dignity.
Plan Of Correction
1. The facility maintenance department will conduct a review of 100% of all assigned call bell pagers in the center to ensure all are programmed and fully operational by 5/31/2025. 2. The Director of Nursing/designee will educate all healthcare center staff on the pager protocol and call bell policy by 6/15/2025. 3. The nursing supervisor/designee will conduct random audits of pagers to ensure all assigned staff have operational pagers and that they are in use. The frequency of audits will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action. 4. Call bell response times will be audited. Audits of random call bells will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action. 5. Call bell audits will be reviewed by visiting Administrator/designee with resident council for three months and the residents' feedback will be reviewed by the NHA/designee with the QAPI committee for further recommendation or action.