Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for four residents, resulting in significant delays in meeting resident needs. Observations, interviews, and record reviews revealed that residents frequently experienced extended wait times for staff to respond to their call lights, with some instances exceeding one hour and, in one case, up to two hours. Device Activity Reports confirmed numerous occurrences where call lights were not answered within the expected timeframe, with many responses taking between 22 and 168 minutes. The DON confirmed that call lights should be answered in less than 20 minutes, but this standard was not met. One resident with a history of cerebral infarction, hemiplegia, diabetes, and other complex medical needs reported waiting up to two hours for assistance, particularly during evening shifts. Another resident with moderate cognitive impairment and multiple health conditions described waiting up to 1.5 hours for call light responses. A third resident, dependent on staff for most activities of daily living and with a history of falls and skin issues, was observed by the surveyor to have their call light ignored by multiple staff members over a period of more than 30 minutes, despite visible indicators that the call light was active. A fourth resident with hemiplegia, cerebrovascular disease, and other chronic conditions also reported frequent delays, sometimes waiting up to two hours for staff response. The documented delays in call light response were corroborated by both resident interviews and electronic call system records, which showed repeated and prolonged response times well beyond the facility's stated expectation. Staff members, including nurse aides and other personnel, were observed walking past rooms with active call lights without checking on the residents' needs, further contributing to the deficiency.