Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for five out of five sampled residents, resulting in prolonged wait times for assistance. Multiple residents, all with good cognitive status as indicated by their BIMS scores, reported waiting up to two hours for their call lights to be answered. One resident, who had chronic obstructive pulmonary disease (COPD), major depressive disorder, and was dependent on supplemental oxygen, described having to leave her room to seek help in the hallway after her call light was not answered. Another resident confirmed witnessing this event and stated that staff were observed laughing and joking outside the room while call lights were ignored. Residents expressed frustration and emotional distress due to these delays, with one resident reporting feelings of anger, worthlessness, and a lack of motivation to eat or participate in daily activities. Family members and residents reported these concerns to facility staff and during Resident Council meetings, where the issue of delayed call light response was repeatedly raised as ongoing. Facility records and interviews confirmed that department heads were conducting daily call light audits in response to these concerns. On one occasion, the Assistant Director of Nursing found a resident in the hallway seeking help after a long wait, and staff were unable to provide documentation of timely responses or progress notes regarding the incident. The facility's policy required call lights to be answered as soon as practicable, but this standard was not met according to resident and family reports, as well as direct observations. Additional residents corroborated the ongoing nature of the problem, with one stating that while they did not frequently use the call light, other residents continued to experience long wait times. Roommates confirmed that during extended delays, they would use the bathroom emergency light to prompt a faster response from staff. Resident Council meeting notes from multiple months documented persistent concerns about untimely call light responses, indicating that the deficiency was not an isolated event but a recurring issue affecting multiple residents.