Resident Left Unattended and Unable to Access Call Light
Penalty
Summary
A resident with a recent pelvic fracture, who was alert and oriented, reported that on her first night in the facility she was unable to locate her call light when she needed to use the bedpan. The resident stated that no staff came to check on her, resulting in her urinating in her brief and remaining in a soiled state. She described feeling frustrated, humiliated, and eventually scared due to the lack of assistance, which led her to call 911 for help. When staff responded after being notified by the police, the resident was found wet and upset, and the call light was discovered tied to the bed rail, though the resident had not seen it. Staff interviews confirmed that the resident was alert, oriented, and able to communicate her needs, but had not received timely assistance. The LPN and CNA involved acknowledged the resident's distress and the delay in care. The facility's policy requires staff to respect residents' privacy and dignity at all times, but this was not upheld in this instance, as the resident was left unattended and in a state of discomfort for an extended period.