Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights for four sampled residents were answered promptly, as required by their care plans and facility policy. Resident 1, who was dependent on staff for bathing and toileting and at risk for falls, reported waiting an hour for assistance after pressing the call light to get help for a confused roommate. When no staff responded, Resident 1 attempted to transfer independently to a wheelchair to seek help and subsequently fell. Resident 1's care plan specifically required that call lights be within reach and that staff respond promptly to all requests for assistance. Other residents also reported significant delays in staff response to call lights. One resident stated that during the night shift, it could take 15-30 minutes for staff to respond after midnight. Another resident reported waiting up to an hour for assistance, which exacerbated their anxiety and breathing difficulties. These accounts were corroborated by the facility's Resident Council Minutes, which documented general complaints about long response times to call lights, particularly during the overnight shift. Record reviews showed that the affected residents had various medical conditions, including acute kidney failure, diabetes, history of falls, hypertension, muscle weakness, congestive heart failure, COPD, insomnia, dementia, and hemiplegia. The facility's policy required prompt and courteous responses to call lights, but interviews and documentation indicated that this standard was not consistently met, resulting in unmet needs for residents who required substantial or total assistance with activities of daily living.