Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to respond to residents' call lights in a timely manner, as evidenced by multiple resident accounts and staff interview. One resident, admitted with adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease, and low back pain, required maximum assistance for standing and toileting. This resident reported activating the call light for help reaching a urinal, but after waiting for half an hour without response, attempted to manage independently, resulting in a fall and self-reported hip injury. The resident stated that staff perceived him as independent due to his cognitive status, despite his physical needs. Another resident with Bell's Palsy, atrial fibrillation, and left-side paralysis, who was cognitively intact, reported that call lights often took a long time to be answered, including an instance where she waited an hour to be changed. A third resident with muscle weakness, COPD, and diabetes, also cognitively intact, described frequent delays in call light response, sometimes waiting up to an hour, and recounted being ignored by staff who walked past while her call light was on. The Director of Nursing acknowledged the facility's outdated call light system and lack of monitoring capability, and no facility policy regarding call lights was provided.