Failure to Maintain Call Bell Accessibility for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain the call bell within reach for two residents who were cognitively impaired and required significant assistance with activities of daily living. For the first resident, who had diagnoses including non-Alzheimer's dementia, muscle weakness, and a history of polio, the care plan specifically required the call bell to be within reach due to her dependence on staff for most ADLs. Observations revealed that the call bell was placed out of her reach, coiled above her right shoulder, and later found on the floor. The resident expressed that she needed the call bell within reach and had needed help in recent days. Staff entered the room but did not ensure the call bell was accessible, only noticing and correcting the issue after it was pointed out. The second resident, who had renal insufficiency, diabetes, hemiplegia, and muscle weakness, also had a care plan intervention requiring a reachable call bell. During interviews and observations, the resident was unable to locate her call bell, which was found dangling between the mattress and the floor, and later behind the bed close to the wall. The resident stated she did not know where her call bell was and agreed it would be beneficial to have it within reach. These findings demonstrate that staff did not consistently follow care plan interventions to ensure the call bell was accessible to residents who were dependent on staff for assistance.