Failure to Ensure Staff Use of Call Bell Pager System
Penalty
Summary
The facility failed to ensure that a functioning call system was available and used by staff to respond to residents' needs in a timely manner. A resident reported having to wait two hours for assistance with personal care over a weekend and stated that staff did not respond to the call bell system, leading the resident to resort to yelling for help. During the survey, the resident demonstrated the use of the call bell, but staff in the hallway were not alerted, and a Geriatric Nursing Assistant (GNA) did not have the required pager to receive such alerts. Further interviews with staff and administration revealed that several staff members, including nurses and GNAs, did not have pagers as required by facility policy. Some pagers were reported as lost or taken home by staff, resulting in inconsistent use of the call bell alert system. The Director of Nursing (DON) confirmed that all nursing staff should have pagers to receive alerts from the call bell system, and that staff without pagers were expected to conduct frequent rounds. However, observations and interviews indicated that this protocol was not consistently followed, as multiple staff members did not have pagers and were not promptly alerted to resident needs. The deficiency was evidenced by the resident's prolonged wait for assistance and the lack of an effective system to ensure timely staff response to call bells in resident rooms and bathrooms.