Failure to Ensure Accessible Call Bell and Timely Staff Assistance
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s need to obtain staff assistance by ensuring access to a call bell. The facility’s own policy on call lights, last reviewed January 22, 2026, states that staff must ensure residents have access to the call light and that all staff who see or hear an activated call light are responsible for responding. Resident 1, who was admitted with bilateral lower extremity amputations (left leg above knee and right leg below knee) and was cognitively intact with a BIMS score of 15, required staff assistance for basic needs. During an observation, the resident’s room contained multiple bags of personal items and clothing, and the resident asked the surveyor to hand him the call bell. The call bell cord was found wrapped twice around the undercarriage of the bed frame and positioned behind the resident’s head, out of reach. When the surveyor attempted to provide the call bell, the cord was caught under bags located behind the bed, limiting its length and requiring the resident to bend his arm backward to reach it. The resident could not explain how the call bell came to be placed on the bottom part of the bed behind his head and out of reach. The Nursing Home Administrator acknowledged that the facility had previously discussed clutter in the resident’s room with the resident but that the matter had not been resolved. Resident Council minutes documented concerns from residents, including this resident, about call bell response times and difficulty receiving toileting assistance during the night shift, and a grievance related to call bell response was filed, with audits initiated but no documented resolution at the time of survey. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing, and the deficiency was cited under 28 Pa. Code 201.29(a) Resident rights.
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