Based on clinical record review, observations, and staff interview it was determine that the facility failed to accomodate resident needs regarding the accessibility to call bells for three of 23 sampled residents. (Residents 33, 37, 55)
Clinical record review revealed that Resident 33 was admitted to the facility on April 11, 2018 with diagnoses that included dementia and depression. Review of the Minimum Data Set (MDS) assessment dated January 2, 2019, revealed that Resident 33 was alert and oriented and required extensive assistance from staff for toileting and bed mobility. On March 5, 2019 at 10:07 a.m., Resident 33 was observed attempting to get up from his bed. Resident stated he needed to use the bathroom. The resident further stated "my call bell is not near me, and I can't reach it". The care plan dated January 9, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach including his call bell.
Clinical record review revealed that Resident 37 was admitted to the facility on December 31, 2018 with diagnoses that included dementia and depression. Review of the MDS assessment dated January 7, 2019, revealed that Resident 37 was cognitively impaired, was at risk for falls and required extensive assistance from staff with activities of daily living. The care plan dated February 27, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach that included his call bell. Observation on March 5, 2019 at 9:15 a.m, revealed that the resident was out of bed in his wheelchair with his call bell behind him and on the floor and not within reach.
Clinical record review revealed that Resident 55 had diagnoses that included stroke, paraplegia, and impaired vision. The MDS assessment dated January 21, 2019, revealed that Resident 55 was cognitively impaired and required total assistance from staff for transfers. Observation on March 6, 2019 at 1:09 p.m., revealed that the resident was out of bed seated in his wheelchair but his call bell was behind him out of reach.
In an interview on March 7, 2019 at 1:00 p.m, Director of Nursing confirmed that the residents did not have access to their call bells.
28 Pa. Code 211.12(d)(1)(5) Nursing services
| ||Plan of Correction - To be completed: 03/18/2019|
It is the policy of Fellowship Manor to assure that all residents have a call bell or acceptable alternative device within reach of each resident at all times.
On March 7, 2019 the ADON conducted an investigation of the circumstances surrounding the event with Resident 33. The CNA caring for the resident on March 5, 2019 was interviewed as to the placement of the call bell on that day. The CNA indicated that she had placed the call bell with in this residents reach after giving care and she feels that call bell was displaced when the resident attempted to sit up at the side of the bed. On this same day it was decided that due to resident 33's cognitive /dexterity issues that a tap bell would be more appropriate. An order was obtained and the comprehensive care plan was updated to reflect the change.
On March 7, 2019 after becoming aware of the observation that resident 37's call bell was not in reach an investigation was conducted by the ADON with the CNA responsible for resident's care. The CNA indicated that this residents wife was in to visit and most likely returned the resident to the room without making the staff aware and as a result the call bell was not placed in reach. This may be plausible but could not be confirmed. On this same day the resident's wife was educated by the ADON as to her responsibility in assuring that the staff is aware when she returns the resident to his room. The staff on the unit were made aware of the observed situation and education was given to reinforce that call placement within the reach of the resident is required at all times without exception and is the direct caregiver's responsibility.
On March 7, 2019 after becoming aware of the observation that resident 55's call bell was not in reach an investigation was conducted by the ADON with the CNA responsible for resident's care. The CNA assigned to the resident indicated that the private companion had returned the resident to the room and did not place call bell within reach. CNA was counseled as to the fact that although there is a companion with the resident the nursing staff is accountable to assure that call bells are within reach.
On March 7, 2019 a "Read and Sign" education was provided to the staff to reinforce the call bell placement requirements. The ADON verbally spoke with the companion regarding call bell placement on March 8, 2019. On March 8, 2019 the DON also sent an e-mail to all staff reinforcing their responsibility to inform family and companions to report when resident s is placed back in their rooms.
Beginning March 18, 2019 the DON/designee will conduct a random sampling audit to assess compliance to call bell placement. Sample size will include 10 residents on each shift 5 days a week for two weeks and then beginning April 1, 2019 weekly thereafter. Any noted concerns with non-compliance will be addressed immediately. Results of the auditing process will be reported at least quarterly to the Quality Council. Auditing will continue until substantial compliance is achieved.