A resident with intact cognition and a history of schizoaffective disorder, bipolar type, was observed sitting on the bedside without any call bell available to summon staff. Surveyors found no call bell cord plugged into the wall and no call bell present in the room, despite facility records from recent nonclinical rounds indicating that a call bell had previously been in place. A staff member and the Nursing Home Administrator confirmed that the resident did not have access to a call bell at the time of the survey.
A resident in room [ROOM NUMBER], Bed C reported that the bathroom/bathing area call bell did not work, and testing confirmed that pressing the red button failed to activate either the panel light or the hallway light. An LPN verified the call light was nonfunctional, and the Assistant Maintenance Manager acknowledged ongoing problems with this specific call bell and its wall panel. The Administrator also confirmed persistent issues with this call bell and believed the bed was striking the wall panel and causing repeated malfunctions.
Surveyors found that the call bell system in multiple rooms on three units illuminated in the hallway but did not produce an audible alarm when activated. A resident with chronic pain and dysphagia, dependent on staff for toileting and dressing and care planned for fall risk with a call light intervention, reported his call bell had not worked properly for two days, which was confirmed on observation. Another resident with diabetes and insomnia, also care planned for fall risk with a call light intervention, reported that his call bell worked only sporadically. Staff and the Administrator acknowledged that the call bells had been lighting but not sounding since the previous day.
The facility failed to maintain a fully functional resident call bell system on one nursing unit, including bathrooms and the shower room. Staff, including an LPN and nurse aides, reported that they must visually watch corridor call lights because the audible call light system does not work and the shower room call light alarms continuously. During observation, the shower room light was alarming, a resident’s call light above the door was illuminated with no audible alarm, and the central light panel showed the shower room light activated. The Maintenance Director confirmed that the call bell system was not being maintained in proper working order to allow residents to call for staff assistance.
A resident who was cognitively intact and needed moderate assistance with transfers and toileting had repeated falls and unsafe self-transfers after being reminded to use the call bell for help. The resident reported staff did not answer the call bell in a timely manner, and survey observation confirmed the call system was not fully functioning because it did not alert the nurse's station when activated.
The facility failed to maintain a functional call bell system on one hall, where the installed system relied on a small digital display at the nurse's station that only briefly beeped, lacked overhead lights, and could show only a limited number of active calls. Staff had to go to the nurse's station and cross-reference a list to determine which room was calling and had no way to know if multiple calls were active without checking the display. Testing showed that one room’s call bell did not register on the digital unit on two separate days. A resident and family member reported that call bells had not been working adequately for months and resorted to using a tap bell and a cow bell so staff could hear them, while another resident’s representative reported that the call bell was not working for that resident.
A resident with a history of stroke, anxiety, and seizures, who was dependent on staff for toileting and dressing, did not have access to a working call system in the bathroom/bathing area. The care plan identified the resident as at risk for falls and directed staff to keep the call light within reach and encourage its use. However, multiple observations over two days showed that no call bell was available in the bathroom/bathing area, constituting a failure to provide the required call system.
A cognitively intact resident with cancer and malnutrition was left without an accessible, functioning call bell after an RN unplugged the call system from the wall in an attempt to stop persistent TV sound. The call bell was left on the floor and no alternative call method was provided, despite facility policy requiring call lights to be plugged in and functioning at all times. Staff statements indicated awareness that the call light was not working and that no one ensured the resident had another way to summon help, even as the resident later experienced emesis and could not call for assistance. Documentation also showed a gap in MAR entries during the overnight hours, and the NHA confirmed the failure to provide a fully functioning call bell system, which was cited as immediate jeopardy.
Surveyors found that several residents did not have accessible call bells to request staff assistance. During an observation with the DON, one resident’s call bell was behind a nightstand and covered by a pillow, another’s was on a dresser out of reach, and another’s was behind the bed. Two residents had call bells hanging down and out of reach, and a family member reported that one resident’s call bell was often on the floor. Another resident’s call bell was wrapped behind the bed and not accessible.
A resident’s bedside call light was found to be nonfunctional when activated, as it did not illuminate or sound at the nurse’s station despite facility policy requiring an operable call system at each bedside, toilet, and bathing room. A NA confirmed the call light cord was damaged and needed replacement, and the Administrator acknowledged that the facility failed to maintain a fully functioning call bell system in that room.
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