Failure to Address Call Light Delays and Inconsistent Refrigerator Policy Enforcement
Penalty
Summary
The facility failed to address concerns raised by a resident and their family regarding excessive call light response times and inconsistent enforcement of a new policy prohibiting personal refrigerators in resident rooms. One resident and their family reported that it often took 45 minutes or more for staff to respond to call lights, particularly on weekends, and that these concerns were communicated to the DON but not formally documented or addressed. The family was not offered an opportunity to complete a concern form, and the DON did not consider the conversation a formal complaint because the family did not use specific language indicating a concern. Additionally, the facility recently implemented a policy to remove personal refrigerators from resident rooms, citing safety concerns such as expired food and wandering residents accessing food not intended for them. However, this policy was not applied consistently, as one resident's refrigerator was removed while another resident still had a refrigerator in their room. Staff confirmed that some residents continued to have personal refrigerators because the facility had not yet educated all families about the new policy. There was no documentation that the affected resident or their family received education about the change. The facility's own policies require timely response to call lights and guidance for safe storage of personal food, but these were not followed as documented in the report. The lack of consistent communication, documentation, and enforcement of policies resulted in unequal treatment of residents and failure to honor their rights to dignity, self-determination, and communication.