Failure to Respond to Call Lights Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nursing staff responded to resident call lights within 15 minutes, as required to meet the needs of every resident. Multiple sources, including Resident Council Meeting minutes, call light logs, direct observations, and interviews with residents, family members, and staff, documented repeated delays in response times. Residents and their families reported waiting from 19 minutes to over an hour for assistance, with some residents left waiting for toileting help, transfers, or other care needs. Staff interviews confirmed that it was common practice to reset call lights and tell residents they would return, sometimes resulting in further delays. Specific examples included a resident with moderately impaired cognition and significant physical care needs who waited up to 1 hour and 31 minutes for assistance, and another resident with intact cognition who reported waiting up to 42 minutes on multiple occasions. Call light logs for several residents showed numerous instances where response times exceeded 15 minutes, with some calls unanswered for over an hour. Residents with varying levels of cognitive and physical impairment, including those dependent on staff for toileting and transfers, were affected by these delays. Family members also observed and reported long wait times for their loved ones. Staff interviews revealed that response times were often longer during busy periods, such as after meals, and that staff sometimes prioritized other tasks over responding to call lights. The facility lacked a written policy for call light response times, and both the Director of Nursing and Administrator acknowledged ongoing issues with timely responses. The deficiency was further substantiated by the facility's own documentation and the absence of a formal policy to guide staff actions.