Call Bell Inaccessibility in Resident Room
Penalty
Summary
Surveyors identified a deficiency in ensuring that a working call system was accessible in resident care areas when one resident’s call bell was not within reach while he was in bed. The resident, who had a wedge compression fracture of the fourth lumbar vertebra and was on a subsequent encounter for fracture with routine healing, had been assessed on the 5-day MDS with a BIMS score of 15/15, indicating intact cognitive abilities for daily decision making. On 03/12/26 at approximately 10:45 a.m., the resident was observed lying in bed with the head of the bed elevated to about 45 degrees, while his call bell was on the floor beside the bed and not accessible. During an interview at that time, the resident attempted to drink water and spilled a small to moderate amount on his shirt, then requested something to wipe off the water. When asked to use his call bell for assistance, he stated he could not find it. The resident also reported that he had fallen the previous night, stating that he had pressed the call bell but no one came, and that he had been trying to pull the curtain when he fell onto his left side. Follow-up observations on 03/12/26 showed that at 10:55 a.m. the call bell remained in the same location on the floor, still not accessible to the resident. At 11:14 a.m., CNA #2 entered the room, picked up the call bell from the floor, and placed it at the bedside, stating that she performs resident rounds every 15 minutes. In a final interview on 03/18/26 with the Administrator, DON, ADON, and two corporate consultants, the findings were discussed, and the Administrator stated she had not been made aware of the issue.
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