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F0919
D

Delayed Response to Resident Call Bell Due to Inadequate Call System

Pleasant Hill, California Survey Completed on 08-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's call bell system was answered in a timely manner. The resident, who was quarantined for COVID-19, had a standalone wireless call bell that was not connected to the facility's call light monitoring panel at the nursing station. This call bell did not activate a visual signal outside the room and did not allow for tracking of response times. Multiple observations and interviews revealed that staff responses to the resident's call bell were often delayed, with response times ranging from 10 to 25 minutes or more. On several occasions, the resident had to use a personal cell phone to call the front desk for assistance after waiting for extended periods. The resident reported feeling frustrated due to these delays and had been using the same call bell system for over a week. Staff interviews confirmed that the call bell emitted an audible sound in the hallway, but there was no system in place to monitor or track when the bell was activated. Staff members, including the charge nurse, receptionist, activity director, and nursing supervisor, indicated that they could not always hear the bell, especially if they were not nearby. The facility's policy required immediate response to call lights and completion of tasks within five minutes if possible, but this was not consistently followed for the resident in question. The lack of a properly functioning and monitored call system resulted in delayed responses to the resident's needs.

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