Failure to Respond Timely to Call Light Results in Prolonged Incontinence Episode
Penalty
Summary
A deficiency occurred when staff failed to respond to a resident's call light in a timely manner, resulting in the resident being left wet for an extended period. The facility's policy required staff to respond to all call lights within 15 minutes, with incontinence needs considered high-priority. However, documented call light response times for the resident ranged from approximately 28 to 51 minutes over several days, far exceeding the facility's policy and expectations. Multiple staff interviews confirmed that these response times were not appropriate and that staff should not wait 30 minutes or longer to answer a call light. The resident involved had significant medical needs, including a history of stroke with right-sided hemiplegia, frequent urinary incontinence, and dependence on staff for toileting and personal hygiene. The resident was cognitively intact and able to communicate needs, activating the call light before needing to use the restroom. Despite this, the resident reported being left wet for 30 to 40 minutes while waiting for assistance, leading to episodes of incontinence and emotional distress. The resident also filed a grievance regarding the delayed call light response, stating that the issue persisted and had not been addressed. Staff interviews revealed that the call light system relied on visual monitors at the nurses' station, and pagers intended to alert staff were not operational or missing. Staff acknowledged that any team member could answer a call light, but delays were common, especially during shift changes or when staffing was low. The charge nurse and DON were identified as responsible for ensuring timely responses, but the lack of functional pagers and inconsistent monitoring contributed to the prolonged response times experienced by the resident.