Failure to Ensure Call Bell Accessibility and Timely Response
Penalty
Summary
Surveyors identified that the facility failed to ensure call bell systems were accessible and within reach for multiple residents, and that staff responded to call bells in a timely manner, as required by facility policy. During facility tours, three non-sampled residents were observed in bed with their call bells either hanging on the wall, on the floor, or wedged behind the bed, all out of reach. One resident with vascular dementia and a history of falls was repeatedly found by a family member without the call bell within reach, a concern confirmed by nursing staff. Another resident with osteoarthritis and muscle weakness was observed in a wheelchair beside the bed, with the call bell hanging behind the bed and out of reach, and reported that the call bell was never accessible, especially when in the wheelchair. Additionally, the facility failed to respond to call bells in a timely manner. The call bell monitoring device at the nurses station showed that a resident's call bell had been sounding for 30 minutes before a CNA responded, and on another occasion, the same room's call bell went unanswered for 20 minutes. The resident in this room, who had multiple diagnoses including diabetes, seizure disorder, and a recent amputation, reported consistently long wait times for staff response. Interviews with staff, including the DON and unit manager, confirmed that call bells should be left within reach and answered promptly, and that response times of 20 to 30 minutes were not considered timely.