Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations, interviews, and documentation. On several occasions, call lights remained unanswered for extended periods, including instances where a call light was on for 16 to 18 minutes before staff responded, and another instance where a call light was left on for 21 minutes. Family members of two residents reported timing call lights being left unanswered for an average of 32 minutes, with one instance lasting up to three hours. Another family member reported a call light being unanswered for one hour, leading the family to provide care themselves. One resident experienced a fall after attempting to use the bathroom without assistance due to a delayed response to their call light, resulting in feelings of disappointment, sadness, anger, and anxiety. Staff interviews confirmed that call lights were not answered within the facility's 15-minute policy due to insufficient staffing and an inability to meet all residents' needs. Resident Council Notes from several months documented ongoing concerns about delayed call light responses, particularly on the evening shift. The facility's administrator acknowledged awareness of the persistent call light response issues. The facility's policy on answering call lights emphasized the importance of timely responses to residents' requests and needs.