Delayed Call Light Response and Incontinence Care
Penalty
Summary
Facility staff failed to respond to resident call lights in a timely manner, with observations showing that a resident's call light remained unanswered for at least 10 minutes on multiple occasions. Staff entered the resident's room, turned off the call light, and left without providing the requested assistance, causing the resident to repeatedly activate the call light. Interviews with residents revealed consistent concerns about delayed responses, with some reporting waits of up to an hour and instances where staff turned off call lights without assisting them. The facility's call light system did not record response times, preventing the administrator from obtaining call light reports. Additionally, staff failed to provide timely incontinence care for a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting. Despite care plan instructions to check and assist the resident every two hours, staff did not offer toileting or incontinence care for nearly three hours, resulting in the resident being observed with a heavily saturated brief and visible incontinence products. Staff interviews confirmed that only one CNA was working on the hall at the time, and that care routines were not consistently followed as directed by facility policy.