F0919

J

Resident Left Without Functioning Call Bell After RN Unplugs System

Pittsburgh, Pennsylvania Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a fully functioning and accessible call bell system for a cognitively intact resident, resulting in the resident being without an active call system in the room and bathroom/bathing area for an extended period. The resident had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx, and was assessed as cognitively intact with a BIMS score of 15. Facility policy required that call lights be plugged in and functioning at all times and that residents unable to use call lights be checked frequently. Despite this policy, the resident’s call bell was disconnected from the wall and left inaccessible on the floor, leaving the resident unable to summon assistance.

According to facility documentation and witness statements, during a night shift an RN attempted to address a problem with the television sound that was controlled through the call system remote. The resident requested that the TV sound be turned off, and when the RN could not silence the sound using the available controls, the RN removed the call system cord from the wall to stop the noise. The RN acknowledged that this action disconnected the call system and that no alternative call method (such as a hand bell or backup cord) was provided to the resident. The resident later reported that the call bell was left on the floor and was not accessible, and that she experienced an episode of emesis and was unable to call for assistance because the call bell had been disconnected.

Additional staff statements indicated that other staff were aware the call light was not working and did not ensure that the resident had an alternative means to call for help. A nurse aide reported being told by the RN that the call light was not working and that she did not know how to fix it. Another undated/unsigned witness statement described a staff member seeing the call light going off at 2 a.m., being told by the assigned nurse that the light had been broken that shift and that it was fine with no need to enter the room, and therefore not checking on the resident. Facility documentation also showed a gap in the resident’s MAR documentation between 1:25 a.m. and 4:00 a.m. The Nursing Home Administrator later confirmed that the facility failed to provide a fully functioning call bell system for this resident, which was determined to be an immediate jeopardy situation.

Removal Plan

• Tested Resident R1's call bell to ensure proper functioning and verified the resident had access to a functioning call system positioned appropriately to meet the resident's needs.
• Completed an assessment of Resident R1 to ensure no adverse outcomes occurred as a result of the call bell being unplugged; no injuries found.
• Educated staff from all departments on call bell accessibility and what to do if the call bell stops working.
• Inspected and tested all resident rooms and common areas with call bell access for functionality and accessibility; no issues identified.
• Had an outside vendor examine the nurse call system and test all activation points; all found in good working condition.
• Conducted a root cause analysis regarding the call bell issue and performed an audit of the call bell system in all resident rooms and common areas where residents may initiate a call.
• Implemented a preventative maintenance schedule for ongoing monitoring of the call bell system.
• Re-educated staff on daily visual checks of call bell accessibility and reporting procedures for any identified functionality issues.
• Implemented Maintenance Director/designee audits of call bell functionality and maintained documentation, reviewed results at QAPI, and corrected and reported any deficiencies immediately.
• Updated the TELS maintenance tracking system to include conducting a test of the nurse call system.
• Completed immediate corrective action for Resident R1 and completed facility-wide call bell testing, with ongoing preventative maintenance and monitoring to continue.