Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for multiple residents, as documented in Resident Council meeting minutes and individual resident interviews. Residents, particularly those on the 2nd and 3rd shifts, reported that call lights were often left unanswered for extended periods, with staff sometimes entering the room, stating they would return, but not meeting the resident's needs. Meeting minutes from two separate Resident Council meetings indicated that the issue was ongoing and unresolved, with several residents expressing dissatisfaction. The Activities Director also communicated these concerns to the previous DON, noting that the problem persisted across different units. One resident, who required substantial to maximal assistance for toilet transfers and was always continent, reported waiting up to an hour for call light response, resulting in incontinence. Call light logs for this resident showed multiple instances of wait times ranging from over 20 minutes to more than 45 minutes. Staff interviews confirmed awareness of the issue, and the DON acknowledged that reasonable response times should be 5-10 minutes, but audits had not identified problems. The NHA was aware of the concerns but had not initiated an ad hoc review, and grievances from Resident Council meetings were not individually addressed unless resolved.