Failure to Respond Timely to Resident Call Lights and Requests for Assistance
Penalty
Summary
The facility failed to meet the needs of three residents by not responding to call lights and requests for assistance in a timely manner. Resident 1, who was admitted with diabetes mellitus and generalized muscle weakness and was occasionally incontinent, reported calling for assistance during the night shift and not receiving help, observing staff sleeping in the nursing station, and feeling irritated by the lack of response. Resident 2, with diabetes mellitus, age-related debility, and total incontinence, stated he requested to be changed in the evening and again during the night shift, but was not assisted until early morning. He also observed a CNA sleeping in the nursing station and expressed anger and upset over the lack of care. Resident 3, with a history of cerebral infarction and difficulty walking but independent in ADLs, reported calling for assistance during the night shift and not being attended to for approximately two hours, leading to feelings of disrespect from staff. Interviews with staff confirmed that CNAs take turns on 30-minute breaks and are expected to cover each other's responsibilities, with explicit policies prohibiting sleeping in the nursing station. The DON and DSD both stated that while staff may rest during their breaks, sleeping in the nurses' station is not permitted. Facility policies reviewed require immediate response to call lights and prompt fulfillment of resident requests, typically within five minutes if possible. The observed staff behaviors and delayed responses to resident needs were inconsistent with these policies and contributed to the residents' negative experiences.