Failure to Respond Timely to Call Bells and Provide PEG Tube Site Care
Penalty
Summary
Facility staff failed to provide timely responses to resident call bells and did not ensure proper gastrostomy tube (PEG) site care for a resident. Review of call bell logs over a one-week period revealed 114 instances where call bells were left unanswered for more than 30 minutes, with 31 of those occasions exceeding one hour. The facility's policy required all staff to respond to call lights within a reasonable timeframe, defined by the DON as within 15 minutes, or up to 25 minutes if staff were with another resident. Despite this policy, staff did not consistently meet these expectations, and the facility was unable to demonstrate effective monitoring or identification of trends related to call bell response times. Additionally, a resident with a PEG tube did not receive documented site care as ordered by the physician. The order to cleanse the PEG tube site with soap and water and cover with dry gauze every night shift was not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR) for July or August, and no new order was written upon the resident's return from the hospital. Interviews with nursing leadership confirmed that PEG tube care should have been documented and performed according to physician orders, but this was not done, resulting in the resident's PEG tube site being left uncleaned on multiple occasions.