Failure to Provide Working Call System in Resident Bathroom/Bathing Area
Penalty
Summary
The facility failed to ensure a working call system was available in a resident’s bathroom and bathing area. Clinical record review showed that Resident 10 had diagnoses including cerebral infarction (stroke), anxiety, and seizures, and a Minimum Data Set assessment indicated the resident was dependent on staff for toileting and dressing. The resident’s care plan identified a risk for falls and included an intervention for staff to ensure the call light was within reach and to encourage its use. However, during observations conducted on March 3, 2026, at 10:50 a.m. and 12:39 p.m., and on March 4, 2026, at 9:46 a.m., 10:35 a.m., and 11:52 a.m., no call bell was available in the resident’s bathroom/bathing area, resulting in noncompliance with 28 Pa. Code 201.18(b)(3)(e)(2.1) Management and 28 Pa. Code 211.12(d)(5) Nursing services. These findings were based on clinical record review and repeated observations that confirmed the absence of a call bell for Resident 10 despite the resident’s dependence on staff for activities of daily living and the documented care plan requirement that a call light be accessible.
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