Failure to Ensure Timely Response to Resident Call Light and Dignity in Care
Penalty
Summary
The facility failed to ensure dignity and resident choice for a resident who required assistance with activities of daily living, specifically with being transferred to bed. The resident, who had no cognitive impairment and was dependent for transfers, repeatedly activated the call light to request assistance to go to bed after returning from smoking. Despite the call light being on and staff being present at the nurses' station, the resident experienced significant delays in receiving assistance. Observations showed that staff either did not respond promptly or, when responding, did not immediately address the resident's needs, instead stating they would find the assigned CNA or leaving the resident waiting further. On multiple occasions, the resident waited extended periods—up to 26 minutes and, by the resident's account, as long as two hours—before being assisted to bed. Staff were observed sitting at the nurses' station while the call light was sounding, and communication between staff members resulted in further delays. The DON confirmed that staff are expected to respond to call lights promptly and meet residents' needs, regardless of assignment, and that the observed delays were not in line with facility expectations or policy.