Resident Left Without Functional Call System After Call Bell Disconnected
Penalty
Summary
Facility staff failed to ensure that a cognitively intact, trach‑dependent resident had a functional means to contact staff after the resident’s call bell system malfunctioned. The resident, who had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx and was unable to speak due to a tracheostomy, reported that during the night shift a nurse removed the call bell from the wall because of a technical issue and left it on the floor, out of the resident’s reach. Facility documentation and staff statements indicated that the call system’s TV volume function was malfunctioning, and the RN disconnected the call bell from the wall to stop the noise. At that time, there were no alternative call systems, backup cords, or other devices provided to the resident to summon assistance. The resident stated that after the call bell was disconnected and left inaccessible, she experienced an episode of emesis and was unable to call for help. She reported that staff did not come in to check on her and that, without a working call bell, she had to walk out to the nurse’s station to obtain assistance. Facility documentation confirmed that the resident’s call bell was unplugged and that no other way to contact staff was provided, despite the resident’s trach dependence and inability to speak. This sequence of actions and inactions resulted in the resident being left without necessary means and services to request help, constituting neglect as defined in the facility’s abuse and neglect policy.
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