Delayed Call Light Response and Missed Medication
Penalty
Summary
The facility failed to ensure that call lights for two residents were answered promptly, as observed and confirmed through interviews and record reviews. One resident, admitted with metabolic encephalopathy and no memory impairment, reported that call lights often took between 30 minutes to an hour-and-a-half to be answered, including instances when she pressed the call light for her roommate who was unable to get out of bed. Another resident, with hemiplegia and hemiparesis following cerebrovascular disease and no memory impairment, was observed to have her call light ringing for 25 minutes without response. This resident had a care plan instructing her to use the call light for assistance with activities of daily living. During the observation, the second resident was found with a cup of medications left unattended on her bedside table, and she reported that a prescribed medication was missing. She had pressed her call light to notify staff of the missing medication and had been waiting for about 25 minutes. The resident stated that staff frequently took up to an hour to respond to call lights and that she had been left wet and soiled for extended periods due to these delays, leading her to feel neglected. The LPN confirmed the missed medication and that the call light could not be seen from the nurses' station. Facility policy required call lights to be answered as soon as possible, and the DON stated the expectation was within 10 minutes.