Failure to Maintain Functional Call Bell System on 500 Hall
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working on one of six halls (500 hall/Unit 1), as required by its policy that mandates a call bell or alternative device be within reach of each resident in their room, toilet, or bathing area, with staff alerted by visual and audible signals. The installed call system used an oblong digital unit at the nurse's station that displayed two-digit numbers corresponding to room and bathroom call bells and emitted three beeps when the first call was activated. However, the system did not provide ongoing audible alerts, did not illuminate overhead lights down the hall or outside resident rooms, and could only display up to eight active calls at a time. When more than one call bell was activated, subsequent calls displaced earlier numbers on the display without additional sound or visual alerts, and any calls beyond eight were not displayed until earlier calls were cleared. Staff reported that to identify which resident was calling, they had to go to the nurse's station, view the two-digit number on the unit, and then cross-reference a separate list to match the number to a resident room. On the 500 hall, testing and observation revealed that call bell number 47, associated with a specific room, did not display on the digital unit when activated on two consecutive days, a problem confirmed by a CNA and the DON. A resident and family member reported that call bells had not been working adequately for several months, and that the resident had been provided a tap bell by the facility while the daughter purchased a cow bell so staff could hear it. Another resident representative reported that the call bell was not working for that resident. Staff interviews confirmed they had no way to know if more than one call bell was activated unless they physically went to the nurse's station to look at the digital unit, and that the system’s limited display and lack of continuous audible or visible alerts impeded their awareness of active calls. These observations and interviews demonstrated that the call system on the 500 hall was not reliably functioning as intended by facility policy.
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