Communication Breakdown Due to Unanswered Phones
Summary
The facility failed to ensure proper access to residents by not adequately managing their phone system, which resulted in significant communication breakdowns. The phones in the facility were left unanswered, preventing a pharmacy from contacting nursing staff to clarify a physician's medication order. This led to a resident not receiving Paxlovid, a medication for treating mild-to-moderate COVID-19, for five days. Additionally, a confidential complainant was unable to reach staff to discuss an urgent matter due to the facility's phone system issues. The deficiency was observed when the facility's phone rang multiple times without being answered, eventually rolling over to a message system. The receptionist, who was responsible for answering calls during business hours, was unaware of the phone system's mailbox setup. The facility's phone system was new and rang throughout the facility, but neither the Administrator nor the Maintenance Director was aware that calls rolled over to a mailbox after a certain number of rings. The facility's policy indicated that phones should be answered from the business office or nurses' station, but this was not effectively implemented, leading to the communication failures.
Penalty
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Facility staff did not consistently answer telephones, preventing residents and family members from contacting the facility. Multiple calls from the state agency, family members, and outside physicians went unanswered, with no option to leave a message. A resident and a family member both reported having to contact police due to lack of response from staff. Staff and the Ombudsman confirmed ongoing issues with phone access, and the administrator was unaware of recent problems.
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. A resident's daughter reported that her calls were not answered or returned. Observations and staff interviews confirmed that nursing staff were occupied with residents and unable to answer phone calls, and messages left by the BOM were not returned. The Administrator acknowledged that this issue had been previously discussed in staff meetings.
Failure to Ensure Telephone Access for Residents and Families
Penalty
Summary
Facility staff failed to ensure that residents and family members could reliably contact the facility via telephone. Multiple attempts by the state agency to reach the facility by phone on several occasions went unanswered, and there was no option to leave a message. Interviews with staff, the Ombudsman, family members, and residents confirmed ongoing issues with unanswered calls. A registered nurse acknowledged that phones sometimes went unanswered, especially during periods of short staffing, and the Ombudsman reported receiving complaints from families about this issue. Family members described repeated unsuccessful attempts to contact the facility, including one instance where a family member had to involve the police for a wellness check due to lack of response. Outside physicians also reported being unable to reach facility staff. A resident reported that after waiting 90 minutes for a response to his call light, he attempted to call the facility for assistance but received no answer, ultimately contacting the police for help. The administrator was aware of previous concerns but was not aware of the specific phone system issues on the dates in question. These findings indicate that the facility did not provide immediate access to residents as required, affecting the ability of residents and their families to communicate with staff and receive timely assistance.
Failure to Answer and Return Phone Calls
Penalty
Summary
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. Resident #42's daughter reported that her calls to the facility were transferred to the nurse's station but were never answered, and her messages were not returned. An observation confirmed that calls to the nursing station were not answered, and messages left by the Business Office Manager (BOM) were not returned. Interviews with nursing staff revealed that they were occupied with residents and unable to answer phone calls. The BOM confirmed that written messages were left at the nurses' station, and the Administrator acknowledged that this issue had been previously discussed in staff meetings. This deficiency was investigated under Complaint Number OH00152016.
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