Failure to Respond Timely to Call Light Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to respond in a timely manner to a resident's request for toileting assistance, resulting in the resident attempting to transfer independently and sustaining a head laceration that required emergency medical care. The resident, who had intact cognition, was occasionally incontinent of bladder, required maximum assistance for transfers and toileting, and was unable to ambulate. The care plan specified that the resident needed assistance of one staff member and a mechanical stand aid for transfers and should be toileted every three hours. On the day of the incident, the resident had last been toileted several hours prior and had used the call light to request assistance, which was not promptly answered. Staff interviews and documentation revealed that the resident activated the call light and was told she would be the next to receive assistance, but staff prioritized assisting two other residents who were considered high fall risks. The call light remained on for 38 minutes before staff responded, at which point the resident was found on the floor with a significant head injury. The resident was not wearing appropriate footwear at the time of the fall, as required by her care plan, and was found to be incontinent of urine. Staff acknowledged that the unit was busy and that the resident had to wait a long time for help, leading her to attempt to go to the bathroom on her own. The facility's policies required prompt response to call lights and implementation of care-planned interventions to prevent falls. Despite these policies, staff did not respond to the resident's call light in a timely manner, nor did they ensure the resident was wearing appropriate footwear. The failure to provide timely assistance and adhere to the resident's care plan directly contributed to the resident's fall and subsequent injury.