Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
Staff failed to answer call lights in a timely manner for three of four sampled residents. One resident, admitted with acute respiratory failure and protein calorie malnutrition, reported having to wait a long time to be changed after using the call light for incontinence care. This resident was observed to be on continuous oxygen and unable to walk, and stated that delays occurred whenever she needed assistance after incontinence episodes. Another resident, with encephalopathy and cerebrovascular disease, stated that it sometimes took 30 minutes for her call light to be answered, depending on staff busyness. This resident was dependent on staff for toileting, personal hygiene, dressing, and bed mobility. A third resident, with a right humerus fracture and shoulder dislocation, reported that her call light was ignored for 15 minutes late at night before staff responded. This resident required substantial assistance for bed mobility, toileting, and dressing. Observations on the unit revealed multiple unanswered call lights. Interviews with facility leadership confirmed that the expectation was for call lights to be answered within 2 to 3 minutes, and that 30 minutes was considered too long. The facility's policy required timely responses to resident requests, with staff expected to communicate estimated response times and seek assistance if needed. Despite these policies, staff did not consistently respond to call lights promptly, as evidenced by resident reports and direct observation.