Failure to Respond to Call Lights and Provide Timely ADL Care
Penalty
Summary
The facility failed to respond to call lights and provide activities of daily living (ADL) care in a timely manner for one resident and a group of eight confidential residents. Specifically, a resident was observed waiting for over an hour to have their brief changed, with their call light out of reach on the floor. Staff entered the resident's room to deliver a breakfast tray but did not address the resident's care needs. On a follow-up visit, the resident activated their call light due to a wet brief, but multiple staff members walked by without responding. A staff member deactivated the call light without providing assistance, and the resident had to reactivate it before the Director of Nursing (DON) responded. The resident's electronic medical record indicated they were admitted with respiratory failure and COPD, had moderately impaired cognition, and were dependent on staff for toileting. Resident council meeting notes from December 2024 to March 2025 highlighted concerns about delayed ADL care and long call light wait times. A group of eight residents reported that when agency staff were on duty, call lights were often ignored, and care was delayed. The facility's policy stated that staff should respond to call lights regardless of assignment and only turn off the light once the resident's request is met.
Plan Of Correction
Element 1: Cited Residents Resident R152 currently resides in the facility. The Facility failed to respond to call lights and provide activities of daily living care in a timely manner. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed baseline audit to ensure residents call lights are being answered in a timely manner based on resident interviews and observation. Element 3: Education Staff will be educated on the facility call light policy to ensure call lights are answered in a timely manner. Element 4: Audit Administrator or designee will complete a random audit 7x a week for 4 weeks to ensure the call lights are answered in a timely manner according to facility policy based on resident interviews and observation. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.