Delayed Incontinence Care Due to Untimely Call Light Response
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type II diabetes, chronic heart failure, hypertension, and bowel incontinence, did not receive timely incontinence care. The resident was dependent on staff for toileting and had an indwelling suprapubic catheter. The care plan required staff to check for continence, offer toileting assistance, and provide incontinence care with protective barriers after each episode. On the day of the incident, the resident's call light was on for approximately 40 minutes before any staff entered the room, despite multiple staff passing by. When a nurse entered, she administered medication but did not provide incontinence care, instead stating she would notify the aide. The resident reported waiting all morning for care and expressed dissatisfaction with the response. Subsequent interviews with staff confirmed that call lights should be answered within ten minutes, and the delay was acknowledged as excessive. The assigned CNA stated she was busy assisting other residents and had not yet attended to the resident in question, but did not feel the facility was short-staffed. The LPN and interim DON both verified that the response time was not appropriate and that any staff member could answer a call light to assist residents. The deficiency was identified through record review, observation, and interviews, and was cited as a failure to meet the resident's incontinence care needs in a timely manner.