Failure to Provide Timely Incontinence Care and Call Light Response
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for several dependent residents, as evidenced by record reviews, direct observations, interviews, and policy review. Multiple residents with significant medical conditions, including chronic kidney disease, cognitive impairment, limited mobility, and incontinence, were observed not receiving prompt care after activating their call lights. In one instance, a resident repeatedly called for help to be changed, but staff either turned off the call light without providing care or failed to respond for an extended period, despite the resident's continued requests and visible distress. Facility policy required that call lights not be turned off until the resident's needs were met, but this was not followed, and electronic call light audits showed a significant number of delayed responses. Additional observations revealed that other residents requiring moderate assistance for toileting and mobility also experienced delays in care. Staff were seen turning off call lights and leaving rooms without addressing residents' needs, and some staff were unaware of the specific requests made by residents. Interviews with residents confirmed that their needs were not met in a timely manner, and that staff often left after turning off the call light, sometimes not returning to provide the requested assistance. Staff interviews indicated a lack of awareness or adherence to the facility's call light response procedures. Further review of records showed that a resident's power of attorney had to contact the facility to report that the resident had not been checked or changed for several hours, contrary to the facility's policy of checking and changing every two hours. The incident was documented, and staff were reminded of the policy, but the deficiency was confirmed through interviews and documentation. Facility policies clearly outlined the expectation for timely response to call lights and incontinence care, but these were not consistently followed, resulting in unmet care needs for multiple residents.