Failure to Maintain Functional Call Bell System on First-Floor Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the first-floor nursing unit was adequately equipped with a functional resident call bell system, as required by facility policy. The policy stated that residents must be provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. During interviews and testing on the first-floor unit, multiple resident room call bells, including those for two roommates and additional rooms (125, 126, 127, 128, 130, and 131), were found not to activate lights at the bedside, outside the rooms, or at the nursing station. A nursing assistant confirmed that these call bells were not working. A licensed nurse reported that one bed’s call bell had been nonfunctional for approximately two months, and a temporary small black call bell receiver had been provided instead. The unit manager stated she was not aware that these call bells were not functioning and verified that they were not sending signals to notify staff. Further review showed that the maintenance log for the prior three months contained only three tickets related to a call bell issue in one first-floor room, and the most recent call bell audit had been conducted several months earlier. At a resident council meeting, multiple alert and oriented residents reported that call bell problems had been occurring intermittently for about a year and a half. One resident later reported being given a small black call bell labeled with a number rather than her room and bed, and stated that night-shift nurses did not have a key list to match the numbered device to specific residents, resulting in her call not being answered. She also reported having to contact the receptionist and be transferred to the nursing station when her calls were not answered, and on another occasion stated that her call bell use again did not result in a response until she called through the receptionist. The administrator acknowledged prior issues with some call bells, stated that this was the first time he became aware of a major problem on the first floor, and a vendor later reported that the main call bell box needed replacement, with further repairs possibly required.
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