Delayed Call Light Response Leads to Resident Harm and Complaints
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for two out of three residents reviewed for accommodation of needs. One resident, who is dependent on staff for toileting and has a stage 2 pressure ulcer, reported having to press her call light multiple times and waiting over two hours for assistance, which she attributed to the development of her bedsore. This resident also attends dialysis three times a week and requires prompt assistance upon return due to fatigue. Another resident, with a history of stroke and left-sided hemiparesis, reported waiting one to two hours for call light responses, leading her to attempt self-transfer, resulting in a fall. She also reported delays in assistance after incontinence episodes. Resident Council minutes from multiple months documented ongoing concerns about long call light wait times, including staff walking by active call lights without responding and call lights being turned off without providing assistance. The facility's policy requires call lights to be answered within a reasonable amount of time. The administrator acknowledged that complaints about call light response times have been raised in resident council meetings, and audits and education have been conducted in response.