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F0919
D

Delayed Call Light Response for Residents Needing ADL Assistance

Santa Monica, California Survey Completed on 05-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to answer call lights in a timely manner for two residents who required assistance with activities of daily living (ADLs). One resident, admitted with diagnoses including type 2 diabetes, essential hypertension, and generalized muscle weakness, was assessed as cognitively intact and at high risk for falls. The resident's care plan required that the call light be kept within reach and answered promptly. During observation and interview, the resident reported frequent delays in call light response on every shift, sometimes waiting so long that she fell back asleep, which caused her anger and frustration when needing assistance to use the bathroom. Another resident, with diagnoses including dysphagia, essential hypertension, and generalized muscle weakness, was assessed as moderately cognitively impaired and totally dependent on staff for ADLs. This resident reported waiting more than 30 minutes for staff to respond to call lights, resulting in delays for assistance with changing adult briefs or obtaining water, which also led to anger. Staff interviews confirmed that call lights are expected to be answered promptly, ideally within 3 to 5 minutes, and that delays could result in resident distress or emergencies. Facility policy also required call lights to be answered as soon as possible, but no later than 5 minutes.

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