Staff failed to ensure that large wall clocks in the rooms of four cognitively impaired residents were functioning and displayed the correct time. Over several days, surveyors repeatedly observed clocks stuck at the same time or showing inconsistent, incorrect times while residents were in their rooms, either in bed or in wheelchairs. Staff entered these rooms multiple times to deliver care, pick up meal trays, and provide ice and water but did not address or report the non-functioning clocks. Some residents verbally indicated that the clocks were wrong or that they did not know the time when looking at the clocks. The unit manager and DON later acknowledged that accurate clocks are important for resident orientation and that staff should have noticed the problem.
Staff failed to follow a care plan intervention requiring a Breathcall adaptive call bell for a resident with quadriplegia, chronic respiratory failure, tracheostomy, tube feeding, and a sacral pressure ulcer, who was severely cognitively impaired and totally dependent for ADLs. Despite the care plan specifying a Breathcall arm instead of a traditional button call light due to lack of mobility, repeated observations showed only a standard handheld call bell clipped to the bed linens. Interviews with an LPN, CNA, director of specialty care, and DON described processes for selecting adaptive call bells and indicated such devices should follow residents when they change rooms, but the ordered adaptive device was not in place for this resident.
Call Light Not Kept Within Reach: A resident with severe cognitive impairment and right-sided non-functioning was observed in a wheelchair with the touch pad call bell clipped to the bed on the resident’s right side, out of reach of the left hand. The resident indicated the call bell could not be reached until an LPN moved it to the wheelchair tray, where it became accessible. The resident’s care plan included keeping personal items within reach, and the facility policy stated call lights should be available to allow residents to call for assistance.
Bathroom Call Bell Not Accessible From Floor: A resident with a BIMS score of 14, wheelchair use, and assistance needs for toileting had a bathroom call bell that was not reachable from the floor on one side of the toilet. Observation showed the cord hanging just below seat level on the right side, while the left side had open space with no access if the resident fell there. Staff interviews confirmed the resident could not reach the cord from that floor position, and the resident had a high fall risk with prior falls in the room.
Call Bell Not Within Reach: A resident with blindness, hearing loss, schizoaffective schizophrenia, and impaired cognition was observed multiple times with the call bell on the floor behind the head of the bed while in bed and once while seated in a wheelchair beside the bed. The care plan included keeping the call light in reach, and a CNA stated it should be beside the resident. Facility policy required call bells to always be within reach when residents are in bed.
A cognitively intact resident with morbid obesity, bed confinement status, and dependence for transfers and ADLs was not accommodated for her repeated request to get out of bed. The resident said she had been in bed for nearly 3 years and wanted to use the Hoyer lift and receive therapy, but staff reported prior lift attempts seemed unsafe or nearly caused the lift to flip. RN staff said she remained in bed and received daily bed baths, while the ombudsman noted her concerns had been raised at care plan meetings and that the facility was restricting her by not getting her up.
A resident with MS and muscle weakness reported missing showers and preferred showers and a shave, but staff documentation showed repeated bed baths, refusals, and inconsistent shower records. Several residents also had room clocks that were missing or displayed incorrect times, and one resident repeatedly asked staff what time it was and whether it was time to eat because the clock was wrong. Staff and leadership acknowledged that accurate clocks were important for resident orientation and daily routines.
Staff failed to ensure that several residents had access to their call bells, with repeated observations showing call bells placed on the floor and out of reach. Interviews with nursing staff, including RNs, LPNs, and CNAs, confirmed that ensuring call bell accessibility is a shared responsibility, but the facility lacked a written policy on this practice. Leadership acknowledged the expectation for call bell placement, but no supporting documentation was provided.
A resident with significant mobility limitations and pressure injuries was unable to access their call bell, which was found on the floor and out of reach. Despite care plan interventions to keep items within reach and remind the resident to use the call light, staff did not ensure the call bell was accessible, and an LPN acknowledged it had fallen earlier. Facility policy requires call bell cords to be off the floor and properly clipped, but this was not followed.
Staff failed to ensure a call bell was within reach for a cognitively impaired resident with mobility difficulties. The resident, unable to locate or access the call bell while in a wheelchair, was only able to reach it after an LPN intervened and attached it to the resident's shirt. Facility leadership was notified of the incident.
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