Failure to Ensure Timely Call Light Response and Privacy for Residents
Penalty
Summary
Two residents experienced failures related to respect, dignity, and the right to personal property. One resident, who was dependent on staff for toileting and personal hygiene due to chronic pain syndrome and functional quadriplegia, had a call light activated for assistance. Multiple staff members were observed passing by the call light without responding, and the resident reported previous instances of waiting for hours for assistance, sometimes resorting to yelling without receiving help. Staff interviews confirmed that answering call lights was the responsibility of all staff and should occur within a few minutes, but this expectation was not met. Another resident, admitted with dysphagia and requiring assistance with personal care, also reported waiting between 30 minutes to an hour for staff to answer her call light. She described the experience as frustrating and disrespectful. Staff and facility leadership confirmed that the facility's policy required call lights to be answered promptly, typically within 2 to 3 minutes, and that delays beyond 10 minutes were unacceptable. Additionally, the first resident was observed with a Foley catheter drainage bag that did not have a privacy cover, contrary to facility policy. The resident stated that staff never placed a cover on the drainage bag and was unaware if the facility had any. Staff interviews confirmed that covering the drainage bag was required to protect privacy and dignity, and failure to do so could cause residents to feel humiliated or undignified. Facility policies reviewed also emphasized the importance of prompt call light response and maintaining resident privacy and dignity.