§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on interviews with staff as well as facility investigation documents, it was determined that the facility failed to provide care and services in accordance with professional standards of practice related to the call bell system being unplugged at the nursing station on one nursing unit (100 unit) placing the residents at risk for potential harm.
Findings include:
Review of the facility policy "Call Bells: Accessibility and Timely Response" dated December 16, 2025, indicated that staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied, and the facility will ensure the call system alerts staff members directly or goes to a centralized staff work area.
Review of witness statement from Licensed Practical Nurse 1 dated March 4, 2026, at 1:15 p.m., revealed that Licensed Practical Nurse 2 told her on two separate occasions that when she worked 6-10, she did unplug the call bell system during her shift and plug it back in before she left. There was no evidence that this information was reported to a supervisor.
Review of witness statement from Maintenance employee 3 dated March 4, 2026, revealed that he heard Licensed Practical Nurse 2 state that the call bell system was driving her nuts and he witnessed her unplug it from the wall on March 3, 2026, at 8:00 a.m. There was no evidence that he reported this observation to a supervisor.
Review of a witness statement from Licensed Practical Nurse 4 dated March 4, 2026, at 3:07 p.m. indicated that Licensed Practical Nurse 4 received report from Licensed Practical Nurse 2 on March 3, 2026, at 10:00 p.m. then went to another unit. When Licensed Practical Nurse 4 returned to the 100 unit at midnight, she observed that the call bell monitor was not in its usual place and was found to be unplugged on the desk. She plugged the call bell monitor back in and reported the observation to the Assistant Director of Nursing.
Review of witness statement from Licensed Practical Nurse 2 dated March 4, 2026, at 12:42 p.m. revealed that she did unplug the call bell monitor from the wall on the morning of Tuesday March 3, 2026, because it was super loud, long enough to get report, and then plugged it back in. The call bell system was working the entire time she was sitting at the desk other than during morning report. She was sorry if it was moved and it unplugged by itself.
Interview with the Nursing Home Administrator on March 10, 2025, at 2:30 p.m. confirmed that Licensed Practical Nurse 2 did unplug the call bell system at the nurse's station on 100 hall on the above-mentioned date and should not have, and that the above identified staff were aware of the nurse's actions and failed to report it to a supervisor.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 04/15/2026
No residents experienced harm while the 100 nurses station call bell system was disconnected. Additional call systems were functioning at the 100-wing care center desk, the 200-wing nurses station and the 200-wing care center desk. All lights indicating a call need were functioning and working outside of the resident room doors.
An in-service/education will be conducted by March 30, 2026 by the Nursing Home Administrator or designee with all care staff and maintenance addressing the facility's "Call Bells: Accessibility and Timely Response" policy.
On March 25, 2026, maintenance wall-mounted all call bell systems in all nurses' stations and care center stations. The wall jacks were also plated so that the jacks are inaccessible to staff. These measures will render the call bell systems unable to be disconnected by staff.
The Maintenance Director, or designee, will conduct a random audit of the call bell systems weekly x2 and then monthly x2 to ensure wall mounted systems are intact and functioning.
This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
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