§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on clinical record review, group interview, staff interview, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for seven of 18 sampled residents. (Residents 42, 45, 54, 56, 73, 77, 82)
Findings include:
Clinical record review revealed that Resident 45 had diagnoses that included radiculopathy (compressed nerve in the spine that cause pain), muscle weakness, and difficulty walking. The Minimum Data Set (MDS) assessment dated March 6, 2025, indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living such as toileting and dressing.
Clinical record review revealed that Resident 54 had diagnoses that included congestive heart failure, diabetes, muscle weakness, and late onset Alzheimer's disease. The MDS assessment dated March 27, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing.
Clinical record review revealed that Resident 56 had diagnoses that included post polio syndrome (condition that causes gradual muscle weakness) and difficulty walking. The MDS assessment dated February 2, 2025, indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting, dressing, and personal hygiene.
Clinical record review revealed that Resident 73 had diagnoses that included Parkinson's disease and neuromuscular dysfunction of bladder (urinary bladder problems due to a disease). The MDS assessment dated February 7, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting.
During a group interview on April 30, 2025, at 10:00 a.m., Residents 45, 54, 56, and 73 reported that it took long periods of time (30 minutes or more) for staff to answer their call bells and get assistance.
Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, muscle weakness, and difficulty walking. The MDS assessment dated February 1, 2025, indicated that the resident was able to communicate his needs to staff and required assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 10:38 a.m., Resident 42 stated that staff took a long time to answer call bells which has affected his ability to receive care and services in a timely manner.
Clinical record review revealed that Resident 77 had diagnoses that included a history of traumatic injuries, peripheral vascular disease, muscle weakness, and difficulty walking. The MDS assessment dated March 6, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:00 a.m., Resident 77 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner.
Clinical record review revealed that Resident 82 had diagnoses that included partial paralysis to the right side following a stroke, chronic kidney disease, muscle weakness, and difficulty walking. The MDS assessment dated April 5, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:55 a.m., Resident 82 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner.
In an interview on April 30, 2025, at 1:00 p.m., the Administrator revealed that staff were expected to respond to a call light within 15 minutes or less.
Review of the facility form entitled, "Device Activity Report," for Residents 42, 45, 54, 56, 73, 77, and 82, revealed that from April 1 through April 30, 2025, there were 158 occurrences when the call bell response time exceeded 15 minutes which included: April 2, 2025, at 7:39 p.m., Resident 42 waited 68 minutes; April 7, 2025, at 12:37 a.m., Resident 45 waited 58 minutes; April 9, 2025, at 7:36 a.m., Resident 54 waited 91 minutes; April 20, 2025, at 8:16 a.m., Resident 56 waited 20 minutes; April 22, 2025, at 3:46 a.m., Resident 73 waited 65 minutes; April 14, 2025, at 1:53 a.m., Resident 77 waited 168 minutes; and April 9, 2025, at 8:02 a.m., Resident 82 waited 41 minutes.
During an interview on May 1, 2025, at 10:45 a.m., the Administrator confirmed the aforementioned residents waited more than the expected response time of 15 minutes.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 06/30/2025
1. The facility maintenance department will conduct a review of 100% of all assigned call bell pagers in the center to ensure all are programmed and fully operational by 5/31/2025.
2. The Director of Nursing/designee will educate all healthcare center staff on the pager protocol and call bell policy by 6/15/2025.
3. The nursing supervisor/designee will conduct random audits of pagers to ensure all assigned staff have operational pagers and that they are in use. The frequency of audits will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action.
4. Call bell response times will be audited. Audits of random call bells will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action.
5. Call bell audits will be reviewed by visiting Administrator/designee with resident council for three months and the residents' feedback will be reviewed by the NHA/designee with the QAPI committee for further recommendation or action.
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