Failure to Ensure Call Light Accessibility and Timely Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity and safety by not making call lights accessible, resulting in extended response times and lack of respectful treatment for multiple residents. One resident, who is blind and has a history of falls and moderate cognitive impairment, reported difficulty locating his call light, often having to feel around his bed to find it. During observation, his call light was found on the floor under the bed, and staff acknowledged that it was not placed within his reach as required by his care plan. Another resident, who is cognitively intact and requires substantial assistance with toileting, reported being left alone in the hallway for an extended period after lunch without access to a call light. She experienced incontinence and remained in soiled clothing for a prolonged time. Her son confirmed that the call light was often found on the floor and that response times to her requests for assistance were excessively long, sometimes up to two hours. The resident's care plan specified the need for frequent checks and prompt toileting assistance, which was not followed.