Delayed Response to Call Lights for Residents Needing ADL Assistance
Penalty
Summary
Facility staff failed to answer call lights in a timely manner for three residents who required assistance with activities of daily living, including personal hygiene and toileting. Resident interviews during a Resident Council Meeting revealed repeated delays, particularly during the 11PM to 7AM shift, with wait times reported as exceeding 30 minutes to over an hour. One resident reported having to get out of bed and go to the nurses' station for assistance due to unanswered call lights, resulting in missed colostomy care and leakage. Another resident described nearly urinating on himself because staff did not empty his urinal promptly. A third resident reported being left soiled for more than four hours on multiple occasions and stated that complaints to charge nurses did not result in improvement. Record reviews confirmed that all three residents had intact cognitive skills and required varying levels of assistance with ADLs due to conditions such as heart failure, muscle weakness, hemiplegia, and colostomy status. The facility's policy required call lights to be answered as soon as possible, and staff interviews confirmed the expectation that call lights should be answered within three minutes or immediately. Despite these policies and expectations, the documented delays in responding to residents' needs led to residents feeling upset, angry, and embarrassed.