Failure to Address and Analyze Prolonged Call Light Response Times
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified, investigated, analyzed, and responded to ongoing issues with excessively long call light response times. Despite having a QAPI Program Plan that outlined systematic analysis and corrective action for quality issues, the committee did not conduct a thorough investigation or causal analysis regarding call light response times, nor did it develop or implement a specific action plan to address the problem. Meeting minutes and PowerPoint presentations from Quality Council meetings lacked detailed data analysis, specific goals, or monitoring of the effectiveness of any actions related to call light concerns, even though grievances and audit data indicated persistent issues. Multiple grievances were filed by residents over a period of several months, citing long waits for call light responses, sometimes exceeding 30 minutes to over an hour. Some residents reported that their needs were not addressed even after staff responded, and in one case, a resident had to go in their brief due to delayed assistance. Audit sheets intended to monitor call light response times were inconsistently completed, lacked clear definitions of timeliness, and did not always align with call light logs. The data collected was incomplete and not systematically analyzed, and there was no evidence that the QAPI committee used this information to drive improvement. Interviews with facility leadership, including the administrator and DON, confirmed awareness of ongoing call light response issues. However, they acknowledged that audits were not accurate or complete, and that there was no established measurable goal for response times. The QAPI committee did not include call light data in its regular reviews, nor did it conduct a root cause analysis or develop a targeted improvement plan, despite policy requirements to do so. This lack of systematic response and oversight had the potential to affect all residents in the facility.