Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
Staff failed to answer a resident's call light in a timely manner, resulting in the resident waiting approximately 20 to 30 minutes for assistance. During this period, multiple staff members, including CNAs, PTAs, LNs, and other staff, walked past the call light without responding, despite the system visibly blinking and making an auditory alert at the nurse's station. Four staff members were observed sitting at the nurse's station while the call light was active. The Activity Director eventually responded and found that the resident needed a brief change, notifying the CNA for further assistance. Interviews with staff confirmed that all staff are responsible for answering call lights and that the expected response time is within 5-10 minutes. The resident involved had a history of hemiplegia and hemiparesis following a stroke, resulting in left-sided weakness and frequent incontinence. The resident was dependent on staff for ADL care, including toileting, and was able to use the call light to request assistance. The resident reported feeling upset and expressed dissatisfaction with the delay, stating that she sometimes had to yell for help. Staff interviews acknowledged that the wait time was excessive and not in line with facility policy, which requires prompt response to call lights to maintain resident dignity.