Failure to Ensure Call Bell Accessibility and Timely Response to Resident Needs
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' call bells were within reach and could be activated for assistance, and that residents' needs were met in a timely manner after call bells were answered. One resident with cognitive impairment and a history of falls did not have access to a call bell; the device was found tied underneath the mattress and not visible or accessible. The resident reported having to use their wheelchair to go into the hallway to seek help. Staff interviews confirmed that the call bell was not accessible and that the assigned CNA was unaware of this issue. Another resident, who was cognitively intact but had physical limitations and required assistance with activities of daily living, was observed unable to locate or reach their call bell, which was found behind a privacy curtain. When the call bell was finally placed within reach, the resident expressed a need to use the bathroom, but the CNA left the room without providing assistance, despite acknowledging the request. The CNA later stated that the resident was not on his assignment. A third resident reported that when staff responded to their call bell, they would turn it off but not return to provide the needed assistance. Staff interviews revealed that while CNAs and nurses were aware of the procedures for responding to call bells, there were inconsistencies in ensuring residents' needs were addressed after the call bell was answered. Facility policy required call bells to be within reach and functioning, but these procedures were not consistently followed for the residents involved.