Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by prolonged call light response times and unmet personal care needs. Several residents, all with significant physical or cognitive impairments requiring assistance with personal care and toileting, reported waiting extended periods—ranging from 30 minutes to several hours—for staff to respond to their call lights. In some cases, residents remained in soiled briefs or with full urinals for hours, causing discomfort and distress. Family members also observed and reported these delays, noting that staff sometimes turned off call lights before completing the requested assistance and occasionally forgot to return to fulfill the resident's needs. Staff interviews corroborated the residents' and families' accounts, with multiple CNAs and an LPN acknowledging that residents frequently complained about long call light wait times. One CNA admitted to turning off call lights before completing the task, intending to return later, while the facility's orientation materials specifically instructed staff not to turn off call lights until the resident's need was met. Despite these guidelines, the practice of prematurely turning off call lights persisted, leading to further delays and unmet care needs. The affected residents had diagnoses such as major depressive disorder, paraplegia, muscle weakness, paralysis, and cognitive communication deficits, making timely assistance with toileting and hygiene essential. The failure to respond promptly to call lights and to provide necessary personal care services resulted in residents experiencing discomfort and a lack of dignity, as well as frustration and concern from both residents and their families.