Call Bell System Unplugged and Not Reported on One Nursing Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure the call bell system on one nursing unit (100 unit) remained functional and that problems with the system were reported and addressed in accordance with facility policy and professional standards of practice. The facility’s policy on call bells required staff to report problems with the call system immediately to a supervisor or maintenance director and to provide immediate or alternative solutions until the problem was remedied, with the system set to alert staff directly or at a centralized work area. Contrary to this policy, one nurse admitted in a witness statement to unplugging the call bell monitor from the wall on a morning shift because it was “super loud,” leaving it unplugged long enough to receive report before plugging it back in. The Nursing Home Administrator confirmed that this nurse did unplug the call bell system at the nurse’s station on the 100 hall and should not have done so. Additional staff were aware of the call bell system being unplugged but did not report it to a supervisor as required. One LPN stated that another LPN told her on two separate occasions that she unplugged the call bell system during her 6–10 shift and plugged it back in before leaving, with no evidence this was reported to a supervisor. A maintenance employee reported hearing the same LPN say the call bell system was “driving her nuts” and witnessed her unplug it from the wall at a specific time, again with no evidence this was reported. Another LPN, upon returning to the 100 unit after receiving report on another unit, observed that the call bell monitor was not in its usual place and found it unplugged on the desk; she plugged it back in and reported this to the Assistant DON. The survey findings concluded that the call bell system on the 100 unit had been unplugged at the nurse’s station, and that multiple staff members were aware of this but failed to report it, placing residents at risk for potential harm.
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