Delayed Response Due to Malfunctioning Call Bell System
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine sampled residents. According to the facility's policy, all staff are responsible for responding to call bells, and nurse aides, charge nurses, and RN supervisors are required to carry pagers to receive notifications. However, interviews with residents revealed that staff response to call bells could take up to an hour, with multiple reports of delays exceeding 30 minutes. Observations on the second floor showed that while visual call bell indicators were present above hallway doors, there was no audible alert to notify staff unless they were physically present in the hallway. This resulted in active call bell requests going unnoticed for extended periods. Further investigation found that some pagers used by staff were malfunctioning, with issues such as non-working screens that prevented identification of which resident had activated their call bell. Staff confirmed that when pagers were not functioning, the only way to identify an active call bell was by visually checking the hallway indicators, as there was no alternative notification system. In contrast, another unit in the facility had an upgraded call bell system with both visual and audible alerts, leading to faster response times. The Nursing Home Administrator confirmed that the second floor call bell system was not functioning as intended, resulting in delayed responses to resident calls.