Delayed Call Light Response in LTC Facility
Summary
The facility failed to respond to call lights in a timely manner for several residents, leading to significant delays in care. Resident #202 reported waiting up to 30 minutes after pressing the call button during breakfast. Resident #39 experienced an average wait time of an hour, with one instance of waiting three hours after a fall. Resident #17 mentioned an average wait time of ten minutes, but noted a 45-minute wait during an evening when he experienced chest pains. Resident #24 frequently waited longer in the morning due to perceived staff shortages, resulting in her voiding in her brief and waiting in a soiled state for hours. Observations confirmed that call lights were not promptly answered, with staff members prioritizing other tasks such as passing medications and food trays. Staff interviews revealed a lack of clarity and consistency in responding to call lights. Staff member H indicated that another staff member was responsible for answering call lights, but was unsure of their whereabouts. Staff member E stated that it was the CNAs' job to respond to call lights, but acknowledged that it was also part of their responsibility if CNAs were unavailable. Staff member K believed call lights should be answered within five minutes, but there was no direct call light policy in place at the time of the survey. The facility eventually provided a call light policy before the survey concluded, but the deficiency in timely response to call lights was evident throughout the observations and interviews.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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