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Based on observation, record review and interview the facility failed to ensure patient rights to receive care in a safe setting for 1 of 2 Patient's reviewed (Patient #2) with a patient rights complaint reported on her behalf.

Specifically, the facility staff were not following their training and procedures for responding to Patient "Call Lights" which could result in patient safety incidents and/or neglect.

Findings included:

Review of Complaint Intake Information, TX00431608 dated 9/16/22 stated "staff members ignore call lights, they walk by her [Patient #2's] room and do not go in. Call lights are not answered in a timely manner, so she is left lying in urine and feces for long periods of time."

Review of the facility's General Orientation training slide regarding Call Lights, undated, revealed slide number 9 indicated the following:
The facility's call lights were deemed a "No Pass Zone. Meaning:
-Not passing any call lights unless it is an emergency.
-Every patient is our patient.
-Improves patient safety and responsiveness.
-Promotes teamwork.
If you are unable to help with their request, that is OK! Reassure them you will get a member of the care team to assist right away. "

Observations conducted on 9/28/22 from 12:45 PM - 12:49 PM with the facility's Director of Quality Management (DQM) present while at the facility's rear nurses station (back end of the facility) revealed the following:
-Hallway Alarm for room 123 audible alarming with flashing light. Patients identified in room 123 as High Fall Risk.
-Hallway Alarm for Room 113 audible alarming with flashing light.
-Hallway Alarm for Room 111 audible alarming with flashing light.
-The Telemetry monitoring screen was alarming with red flashing alerts.
-The Call light telephone system on the desk was ringing which included the calls from the alarming call lights.

During these observations when Rooms 111, 113 and 123 were alarming, the Telemetry monitor was alarming, and the telephone system was ringing; RN #1 was sitting at the nurses station desk on the computer and remained at the desk. RN #2, who stated she was an ESRD (End Stage Renal Dialysis) nurse was making copies at the copier, and the Unit Clerk #1 was sitting at the nurses station desk and remained at the desk. RN #1, ESRD RN #2 and Unit Clerk #1 did not attend or respond to the audible alarms; or answer the telephone system at the desk where the alarms call into until the DQM directed the Unit Clerk to attend to the call lights at 12:50 PM.

Further observations on 9/28/22 at 12:55 PM with the DQM present at the front end nurses station (front end of the facility) revealed the following:
The Call light telephone system was ringing on the desk. At the desk was a Nurse Practitioner Provider (NP #1) and Licensed Vocational Nurse (LVN) #1. No one answered the telephone system as it continued to ring.

The NP #1 was asked during these observations at 12:55 PM if this was a call light phone system and she said, "I am a Nurse Practitioner."

The LVN #1 was asked during these observations at 12:55 PM if this was a call light phone system ringing in which she responded, "I don't know."

The DQM was then asked during these observations at 12:55 PM if this was a call light phone system ringing in which she responded, she thought it was a "provider phone for Respiratory." The DQM then answered the ringing telephone in which it was identified as the call light system phone ringing and the DQM responded to the patient calling in that someone would be right in to their room to assist them.

During an interview with the facility's Chief Nursing Officer (CNO) on 9/28/22 at 1:00 PM stated it was everyone's responsibility to answer call lights and the facility had implemented "walkies" a month ago to help with the communication of patient needs as an assistance to the call lights. The CNO stated they were trying to establish a baseline of calls and times for determining common themes, utilizing the electronic system to be more effective with call lights. The CNO stated the facility utilizes a "No Pass Zone" to Call lights in accordance with their training.

Further interview with the CNO on 10/28/22 at 2:40 PM stated the facility was going to focus on response to call lights during new orientation training; reset the expectations and ensure patient center focused was a priority.


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