Failure to Uphold Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold residents' rights to dignity and timely assistance, as evidenced by multiple incidents involving delayed responses to call lights and inadequate support with activities of daily living (ADLs). One resident, with a history of right lower leg fracture and muscle weakness, was left on a bedpan for over thirty minutes without assistance, despite using the call light and having a care plan that required prompt response to requests for help. The resident's family member had to seek staff assistance directly at the nurses' station, where a nurse indicated that aides were busy with meal trays and would assist after completing those duties. The same resident was also pressured to sign a refusal for a bath when she only wished to delay it due to fatigue from therapy, rather than refuse it entirely. Another resident, with a history of stroke and respiratory failure, reported waiting up to an hour for assistance to use the bathroom, resulting in urinary incontinence. This resident, who was cognitively aware and required standby assistance for toileting, described feeling humiliated by these delays. A third resident, dependent on staff for toileting due to weakness and age-related debility, reported that call lights were not answered in a timely manner, particularly during the third shift, leading to episodes of incontinence that left pajamas, sheets, and blankets soaked with urine. This resident also experienced staff refusal to assist with transferring to a recliner and to warm up cold food, despite repeated requests. A fourth resident, with diagnoses including spinal stenosis and chronic kidney disease, described waiting up to 45 minutes for call light responses, resulting in both urinary and bowel incontinence. This resident, who was cognitively intact and required substantial assistance with toileting, had not reported the issue due to sympathy for the understaffed facility. Facility policies reviewed indicated that all staff were responsible for responding to call lights and that residents had the right to be treated with respect and dignity. The DON confirmed that the expectation was for call lights to be answered within five minutes.