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F0558
E

Failure to Ensure Prompt Call Bell Response Times

Gettysburg, Pennsylvania Survey Completed on 06-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure prompt response times to resident call bells for four residents over a three-month period, as evidenced by call bell monitoring system reports and resident and staff interviews. The facility's policy requires all staff to be aware of and respond promptly to call lights, regardless of assignment, and to only turn off the call light once the resident's needs are met. However, multiple instances were documented where response times exceeded 20 minutes, with some calls going unanswered for over an hour. Residents reported variable and often lengthy wait times, particularly at night and on weekends, and described situations where they remained on a bedpan for extended periods or avoided drinking fluids due to anticipated delays in assistance. Staff interviews revealed that the Nursing Home Administrator reviews call bell reports only when a grievance is filed or a concern is voiced, focusing on average response times rather than individual incidents. The NHA could not confirm whether staff had responded to the residents in a timely manner and was unable to specify expectations for response times. The Director of Nursing also could not provide clear expectations for call bell response. The facility was cited for failing to reasonably accommodate the needs and preferences of residents, as required by state regulations.

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