Failure to Maintain Functional Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. On the 5th floor, the call bell system was not audible and did not have a centralized location to alert staff in all twenty-nine rooms. Additionally, the visual indicator light above the door did not function in five of these rooms. In ten rooms, alternative manual tap or hand bells, which were part of the facility's interim plan, were not provided or readily available. Observations by surveyors confirmed that residents were unable to reliably summon assistance, with several residents reporting long wait times of one to three hours after using the hand bell, and concerns that staff could not hear the bells. Staff interviews corroborated that the call bell system had been nonfunctional for approximately a year, and that manual bells and 15-minute rounding were implemented as temporary measures. However, these measures were inconsistently applied, as not all rooms had the required manual bells. Facility records and staff interviews revealed that the call bell system was deemed irreparable, and efforts to replace it were delayed due to a lengthy approval process involving multiple departments. Despite ongoing complaints from residents and families, and acknowledgment from facility leadership that the call bell system was critical for resident safety, the system remained nonfunctional for an extended period, leaving residents without a reliable means to request assistance.