Delayed Call Light Response Resulting in Unmet Resident Needs
Penalty
Summary
Staff failed to respond to call lights in a timely manner for five out of six sampled residents, resulting in unmet needs for assistance, particularly with toileting. The facility's own policy required escalating call light responses at specific intervals, but call light logs showed repeated delays, with some calls remaining unanswered for over 20 to 40 minutes. Residents who required substantial or total assistance for toileting, transfers, and ambulation were left waiting, leading to episodes of incontinence and distress. Multiple residents, all cognitively intact except one, reported having to wait extended periods for staff assistance after activating their call lights. These residents had significant medical histories, including recent fractures, use of diuretics, diabetes, heart failure, and mobility limitations requiring wheelchairs or walkers. Several residents described feeling bad or embarrassed after being incontinent while waiting for help, and family members corroborated these delays, noting wait times of up to an hour. The facility's leadership, including the DON and Administrator, acknowledged monitoring call light response times and receiving alerts for excessive delays. However, they were unaware of the full extent of the problem, as they had not identified prolonged response times for all affected residents. Despite daily and weekly reviews of call light logs, the issue persisted, with staff not accommodating residents' needs and preferences for timely assistance, especially for those at high risk for incontinence and falls.