Failure to Maintain Audible Call Bell System in Resident Rooms
Penalty
Summary
The facility failed to maintain a working call bell system on one of its nursing units, as evidenced by multiple observations and interviews during a complaint survey. Family members reported that the call bell in a specific room did not illuminate in the hallway, and staff informed them that the call bell was either not working at the desk or the volume was turned down. Upon investigation, the surveyor found that while the call light illuminated over the doorway when activated, there was no audible sound in the hallway. This issue was confirmed by staff present at the time, who also could not hear the call bell. Additional rooms were tested, and in each case, the call lights illuminated but no audible alert was heard. A resident was observed repeatedly pressing the call bell button without any response, and resorted to using a hand bell, which also could not be heard at the nurse's station. Staff at the nurse's station confirmed they did not hear any call bells ringing. The Director of Maintenance later discovered that the speaker system was turned off, as indicated by a muted speaker icon on the computer screen. The Assistant Director of Nursing and the RN unit manager were unaware that staff could turn off the call bell sound and needed to investigate the cause. The deficiency was communicated to the Director of Nursing and the Regional Representative during the exit conference.