Failure to Maintain Operational Call Bell System and Provide Alternative Means for Resident Assistance
Penalty
Summary
Facility staff failed to maintain an operational call bell system in resident rooms, bathrooms, and bathing areas, resulting in multiple instances where residents had no reliable means to call for assistance. During the survey, it was observed that at least one resident did not have a functioning call bell and no alternative method to summon help. Staff interviews revealed a lack of knowledge regarding the location and distribution of hand bells, with only five hand bells initially found for the entire facility, which houses up to 180 residents. Additional hand bells were later located in a locked maintenance room, but staff were unaware of their availability or how to access them during emergencies. There was no established policy or procedure for staff to follow when the call bell system was inoperable, and staff did not know how to mitigate the risk to residents during outages. Resident interviews confirmed repeated and prolonged outages of the call bell system, with some residents reporting that their call bells were nonfunctional for several days at a time. Residents described situations where they were unable to call for help from their beds or bathrooms, and in some cases, hand bells provided as alternatives could not be heard outside the room. Residents expressed feelings of fear and frustration during these outages, particularly those with limited mobility. Documentation review, including resident council minutes and maintenance logs, showed ongoing and unresolved issues with the call bell system, including entire wings being affected and repeated system failures requiring maintenance intervention. The facility's own policy required monthly inspection and testing of all call systems, including in bathrooms and shower rooms, and documentation of any malfunctions and repairs. Despite this, the facility was aware of ongoing problems with the call bell system but did not provide staff with procedures to ensure residents had a means to call for help during outages. Staff interviews and documentation confirmed that there was no contingency plan in place, and residents were left without reliable access to assistance during repeated system failures.