Failure to Ensure Timely Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for two residents who required significant assistance with care. One resident, admitted with respiratory failure, vent dependence, dysphagia, muscle weakness, and diabetes, was observed to have activated her call light for incontinence care and waited 49 minutes before care was provided. During this period, staff entered the room only to deliver a meal tray, and the CNA responsible was unaware of the request, stating she did not hear the call light or radio due to assisting elsewhere. The Assistant Director of Nursing acknowledged the delay and stated there was no specific expectation for call light response time. The Director of Nursing also confirmed the facility policy was vague and agreed the wait time was excessive. Another resident, dependent on staff for eating and with diagnoses including acute chronic respiratory failure and vent dependence, activated her call light to request respiratory therapy and waited 45 minutes before being seen. The resident expressed uncertainty about when care would be provided. Review of call light audits over a two-month period showed multiple instances where response times exceeded 10 minutes, with the longest being 20 minutes. Staff interviews revealed inconsistent understanding of expected response times, and the facility's policy only stated that staff should strive to answer call lights promptly, without specifying a timeframe.