Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights, resulting in unmet care needs for seven out of nine residents reviewed. Multiple observations and interviews revealed that call lights were not answered within the facility's expected timeframe of 10-15 minutes, with some residents waiting up to an hour. Staff, including CNAs, RNs, and the DON, were observed walking past active call lights without responding, and residents reported frequent delays in receiving assistance, particularly for toileting and mobility needs. Several residents with significant physical and cognitive impairments, such as hemiplegia, hemiparesis, muscle weakness, and severe cognitive impairment, were affected by these delays. Residents described waiting extended periods for help with toileting, resulting in incontinence accidents and, in some cases, falls when attempting to manage their needs independently. Documentation confirmed that some residents experienced repeated falls and accidents directly related to delayed staff response to call lights. Staff interviews corroborated the residents' accounts, with CNAs and RNs acknowledging that all staff were responsible for answering call lights but citing insufficient staffing levels as a barrier to timely responses. The facility's policy required prompt attention to call lights and for staff to remain with residents if unable to immediately meet their needs, but this was not consistently followed. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility policies and care plans.