Failure to Provide Timely Response to Call Lights and Resident Care Requests
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the person-centered care plan, and residents' choices for two residents reviewed for call bell response. One resident, admitted for multiple conditions including hypertension, depression, and a urinary tract infection, was identified as high risk for falls and required frequent assistance due to incontinence. Despite being able to communicate his needs, the resident reported that staff would turn off his call light and state they would notify someone to assist him, but he often waited up to an hour and a half for help. On one occasion, after lunch, the resident waited over 45 minutes for assistance to have his brief changed, despite repeated requests. Staff interviews revealed miscommunication and lack of follow-through, with CNAs not being informed of the resident's needs and some staff declining to assist, stating the resident was not assigned to them. Another resident, admitted for diabetes, urinary tract infection, hypertension, anemia, acute kidney failure, and muscle weakness, also experienced delays in care. This resident, who had good cognitive function and communication abilities, reported that staff would turn off her call light and say they would inform someone else of her request, resulting in wait times ranging from 20 minutes to 2.5 hours. On one occasion, after repeated unanswered requests for pain medication, the resident had to leave her room and go to the nurse's station to obtain the medication herself. The nurse on duty did not recall being informed of the request and attributed the oversight to a busy shift. Facility policy required all staff to answer call lights and ensure that residents' needs were met, even if the initial responder could not provide the requested service. However, staff interviews and resident reports indicated that this policy was not consistently followed, leading to significant delays in care and unmet resident needs. Staff sometimes failed to communicate requests to the appropriate personnel or declined to assist residents not assigned to them, contrary to facility expectations and policy.