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F0550
D

Failure to Promptly Respond to Call Light Compromises Resident Dignity

Glendora, California Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to promptly respond to a resident's call light, resulting in a lack of timely assistance for personal care needs. The resident, who had diagnoses including end stage renal disease, hypoglycemia, muscle weakness, and mobility issues, required substantial to maximal assistance with toileting, bathing, and dressing, and was frequently incontinent. The care plan directed staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. During observations, the resident activated the call light for a brief change and reported that staff typically took 30 minutes or longer to respond, sometimes making the resident wait up to an hour. The resident also stated that staff would sometimes defer assistance until their rounds were complete or would instruct the resident to wait for the assigned staff member, even if another staff member was available. Multiple staff were observed walking past the resident's room while the call light was on, and the call light remained unanswered for at least 10 minutes during the surveyor's observation. Interviews with CNAs revealed that licensed nurses generally did not assist with answering call lights or simple resident requests, leaving the responsibility to CNAs. Both the LVN and DON stated that all staff were responsible for answering call lights and emphasized the importance of prompt responses to meet residents' needs. The facility's policy required staff to answer call lights within a reasonable time, listen to the resident's request, and respond appropriately, but these procedures were not followed in this instance.

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