Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity and respond to call lights in a timely manner, affecting two residents. Resident #104, a male with depression and type 2 diabetes mellitus, reported that his call light often took a long time to be answered, particularly during meal times. His Minimum Data Set (MDS) assessment indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #105, also cognitively intact with a BIMS score of 15, reported that delayed responses to his call light sometimes resulted in him urinating in his pants, causing him distress. His diagnoses included a urinary tract infection, unsteadiness on feet, and weakness. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about long wait times for call light responses. The Resident Council Minutes from several months also documented ongoing issues with call light response times, including instances where aides turned off call lights without addressing resident needs and took excessive time to return. These findings indicate a pattern of inadequate response to resident needs, impacting their dignity and quality of life.
Plan Of Correction
Resident #104 and #105 continue to reside in the facility. Care plans have been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated staff on the Resident Rights Policy and the Call Light Policy. Staff members who have not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will complete an audit of 10 random call lights during and around mealtimes to ensure residents' needs are met in a timely manner. An audit will be completed once a week for four weeks, then once every month for three months, to ensure call lights are being answered in a timely manner. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025