ALTOONA, PA - A federal inspection at Midtown Oaks Health & Rehab Center revealed a complete breakdown of the facility's resident call bell system, creating an immediate jeopardy situation that left residents unable to effectively summon staff assistance for hours at a time.
The July 2024 complaint investigation documented that the facility's call bell system was entirely non-functional, with no audible alerts and nursing staff unaware when residents activated their call buttons. Resident council meeting minutes from April through June 2024 showed residents consistently complained about excessive wait times, sometimes up to an hour, before receiving assistance.
Silent Emergency System Puts Residents at Risk
Federal inspectors observed that call lights were recessed in ceiling fixtures above resident rooms and produced no sound when activated. The lighting system was so poorly positioned that it wasn't visible from nearby rooms, making it nearly impossible for staff to detect when residents needed help.
During staff interviews, Licensed Practical Nurse 5 told inspectors she "relies on the nurse aides to answer the call bells" but acknowledged "they do not make a sound anywhere." She carried no device to alert her when residents pressed their call buttons. Registered Nurse 6, who was new to the facility, stated she was "not sure where the call bells sound to" and was unaware of any alerting devices nursing staff should carry.
The breakdown extended to nursing assistants who provide direct resident care. Nurse Aide 4 explained she tried to "watch for the lights above the resident's door ways" but confirmed there was "no sound" and she didn't know of any device that should alert her. Another aide, Nurse Aide 7, confirmed the call bells "do not make a sound anywhere in the hall or at the nurse's station."
Administrative Failures Compound System Breakdown
The facility's administrator revealed during interviews that staff were previously equipped with pagers designed to alert them when residents activated call bells. The paging system included escalation protocols where nurse aides would be alerted first, followed by nurses if the initial call went unanswered within a specified timeframe.
However, the administrator acknowledged that "at some point, the staff stopped charging the pagers and stopped carrying them." In response to the non-functional call system, she had purchased mini kiosks for staff to use in hallways while charting, theoretically allowing them to observe the ceiling lights when activated. Staff interviewed were unaware of this expectation or procedure.
Medical Consequences of Communication Failures
The inability to effectively communicate with nursing staff creates serious medical risks for residents. When residents cannot reliably summon assistance, they face delays in receiving medication, help with toileting needs, or emergency medical intervention during falls or sudden illness.
For residents with cognitive impairments, mobility limitations, or medical conditions requiring frequent monitoring, a non-functional call system represents a fundamental breakdown in basic care safety protocols. The documented wait times of up to an hour could prove life-threatening for residents experiencing cardiac events, respiratory distress, or falls.
Standard nursing home protocols require reliable communication systems that allow residents to immediately contact staff 24 hours daily. The Joint Commission and Centers for Medicare & Medicaid Services mandate that facilities maintain functioning call systems in all resident rooms and bathroom areas specifically because timely response to resident needs directly impacts health outcomes and safety.
Immediate Jeopardy Declaration Forces Emergency Response
On July 3, 2024, inspectors formally notified the administrator that the facility's communication system failures created an immediate jeopardy situation affecting resident health and safety. This designation indicates conditions that could cause serious injury, harm, impairment, or death to residents.
The facility implemented emergency measures including providing each resident with tap bells or cow bells that staff could hear when sounded. Hall monitors were stationed in each of the facility's four corridors to listen for these temporary alert devices and identify which residents needed assistance.
The emergency response also involved locating the previously abandoned paging devices, replacing batteries, and redistributing them to nursing staff. The facility established procedures requiring staff to sign pagers in and out each shift, with maintenance replacing batteries monthly to prevent the previous charging failures.
System-Wide Training and Infrastructure Overhaul
More than 90 percent of nursing staff received immediate education about the temporary call bell system, with remaining staff scheduled for training before their next shifts. The facility also contacted contractors to either purchase a new call bell system or modify the existing infrastructure to include audible alerts at centralized nursing stations.
The immediate jeopardy designation was lifted the same day after inspectors confirmed the emergency measures were functioning effectively. Each resident had received an audible alerting device, staff training was substantially complete, and the facility had initiated procurement processes for permanent system repairs.
Documentation Failures Compound Care Concerns
The inspection also revealed significant documentation deficiencies in resident medical records. In one case, a resident with dementia and aggressive behaviors was transferred to a hospital and eventually discharged from the facility, but clinical records contained no documentation of discharge planning or communication with the hospital regarding the resident's care transition.
The administrator acknowledged these documentation failures during interviews, confirming that the resident's clinical record was incomplete despite ongoing communication between the facility and hospital regarding the resident's status and discharge plans.
Regulatory Violations and Compliance Requirements
The call system failures violated multiple Pennsylvania nursing home regulations, including requirements for adequate nursing services, management oversight, and licensee responsibility for resident safety. Federal regulations specifically require that working call systems be available in each resident's room and bathroom area.
The documentation deficiencies violated additional state regulations governing clinical record maintenance and nursing service standards. These violations demonstrate broader systemic issues with facility oversight and quality assurance processes beyond the immediate call system failures.
Midtown Oaks Health & Rehab Center, located at 1020 Green Avenue in Altoona, must demonstrate sustained compliance with corrective measures to prevent future safety violations and ensure residents can reliably access nursing care when needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altoona Center For Nursing Care from 2024-07-03 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.