Failure to Maintain Functional Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working for one of its nursing units, specifically the West Hall Nursing Unit. According to facility policy, a call bell or alternative device should be within reach of each resident in their room, toilet, or bathing area, and staff should be alerted to calls by visual and auditory signals. However, observations revealed that the call bell system in the corridors did not illuminate when resident call bells were activated. Maintenance records confirmed that the original call bell system had not been functioning since 4/22/25, and a temporary system installed on 4/29/25 did not provide a visible overhead light. Instead, calls were only displayed on a central screen, and if multiple calls were made before staff responded, earlier calls would not be visible and could be missed. Interviews with residents indicated consistent and prolonged wait times for assistance after using the call bell system, with reports of waiting from thirty minutes to several hours. Residents expressed concerns that staff were often unaware of their calls, especially since the original system stopped working. Some residents reported that due to long wait times, they would attempt to get up by themselves if they could not wait any longer for help. The Nursing Home Administrator confirmed that the central call bell system was not fully functioning to provide visual communication of which room the call bell activation was coming from.