Failure to Ensure Resident Dignity and Timely Call Light Response
Penalty
Summary
The facility failed to ensure the right to a dignified existence and timely response to call lights for two residents. One resident, a 65-year-old with multiple neurodegenerative conditions and cognitive intactness, was observed without privacy during care, with staff entering his room without knocking or identifying themselves, and leaving his door open during personal care. The resident reported feeling disrespected, with staff speaking to him in an aggressive manner and not waiting for his responses, and his representative confirmed repeated instances of lack of privacy and long waits for assistance. Documentation showed that the call light was inaccessible at times and that response times exceeded 20 minutes in 39.3% of calls, and over 60 minutes in another 39.3% of calls, with one instance where the call light was not answered for over an hour and a half. Another resident, who was dependent on staff for all activities of daily living due to multiple sclerosis and other impairments, also experienced significant delays in call light response. The resident reported feeling that using the call light was pointless due to long wait times, sometimes resulting in being left soiled. The call light system data indicated that staff response time exceeded 30 minutes in 24.4% of calls, with some waits as long as 266 minutes. The resident's representative corroborated these concerns, stating that the resident would call her for help when staff did not respond, and that she had to contact the facility herself to request assistance for the resident. Staff interviews revealed inconsistent practices regarding privacy and call light response. Some CNAs stated they closed doors and provided privacy, while others did not consistently follow these procedures. Staff acknowledged that answering call lights promptly was challenging during certain times, such as meals or shift changes, and that there was a lack of clear direction or support for managing high call light volumes. The DON confirmed that everyone was responsible for answering call lights, but also noted that review of call light response times was not consistently performed, and there was no immediate plan to address the delays.