Failure to Timely Respond to Call Light Leaves Resident Unattended on Toilet
Penalty
Summary
A resident with multiple medical conditions, including Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Fatigue, Age-Related Macular Degeneration, and Adjustment Disorder, was left on the toilet for an extended period after activating the call light for assistance. The resident, who was cognitively intact and required partial to moderate assistance with toileting hygiene and supervision or touching assistance with toilet transfer, reported waiting almost two hours for staff to respond to the bathroom call light. During this time, the resident's family attempted to locate staff but was unable to find anyone to help, and the resident expressed significant distress, stating they were begging for help and felt unimportant. The facility's call light system was designed to alert CNAs and, after ten minutes, notify the nurse if unanswered. On the day of the incident, staff were occupied with passing and feeding lunch trays, which delayed their response to the call light. The facility's policy required all staff to respond to activated call lights and ensure resident access to the system, but this was not followed, resulting in the resident being left unattended and experiencing discomfort, disrespect, and anxiety.