Failure to Protect Residents from Neglect and Delayed Response to Call Lights
Penalty
Summary
Residents experienced neglect related to delayed staff response to call lights, with multiple reports indicating that residents waited 10 minutes or longer, and in some cases up to 30 minutes or more, for assistance. Residents described being left in pain, feeling humiliated, and in some cases becoming incontinent while waiting for help. Several residents reported that staff would turn off call lights and either leave without assisting or promise to return but did not, and some staff responded with anger or rudeness when residents requested help, especially at night. These issues were consistently raised in resident council meetings and individual interviews, with residents expressing fear or reluctance to use their call lights due to negative staff reactions. Documentation from resident council meetings over several months showed that concerns about long call light response times and staff behavior remained unresolved. Residents repeatedly reported that staff were rough, rude, or dismissive, and that their complaints were not always addressed or investigated thoroughly. Specific incidents included residents being left in soiled clothing for extended periods, being spoken to harshly, and experiencing physical discomfort or injury due to delayed or rough care. Call light audits confirmed that several residents experienced frequent and prolonged waits for assistance, particularly during busy times such as mornings. The facility's complaint and grievance records revealed a pattern of similar concerns from both residents and staff, including reports of staff ignoring call lights, yelling at residents, and providing rough or disrespectful care. Investigations into these complaints often lacked clear identification of the staff involved and did not always include thorough documentation of follow-up or resolution. Staff interviews indicated that while education on resident rights and abuse was provided, there was no consistent process for monitoring or addressing ongoing concerns, and some staff attributed negative interactions to cultural differences rather than addressing the underlying issues of neglect and disrespect.