Failure to Ensure Timely Call Light Response and Resident Care
Penalty
Summary
The facility failed to ensure timely response to call lights and assistance with care needs, snacks, and incontinence care for multiple residents. During a Resident Council meeting, all attendees reported excessive delays in call light response, with some residents stating that grievances were not resolved and that staff were often inattentive, distracted by personal cell phones, or socializing with each other. Residents also reported inconsistent distribution of snacks and assistance with activities of daily living (ADLs), such as showers and incontinence care, with one resident stating she had not received a shower in over a month since returning from the hospital. Specific incidents included a resident with burns and a PICC line who waited 55 minutes for a nurse to respond to a beeping IV pump alarm, ultimately having to silence the alarm himself. This resident also experienced delays in wound care and reported that a nurse refused to change his dressing, stating it was not her job. Documentation showed that staff sometimes turned off call lights without meeting residents' needs, and not all staff received education or corrective action following these incidents. Other residents reported waiting over 30 minutes for call light responses, with one resident left without a functioning call light and another left on the toilet for nearly 50 minutes waiting for assistance. Facility records, including alarm event reports, confirmed multiple instances where call lights and bed exit alerts went unanswered for extended periods, sometimes exceeding an hour. Residents described being left in soiled briefs and wet bedding overnight, and one resident had to call the front desk for help when the call light system failed. Interviews with staff and the state ombudsman corroborated these findings, noting that staff sometimes entered rooms only to turn off call lights without providing the requested assistance. The facility's own policy required prompt call light response and staff education, but these standards were not consistently met.