Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, resulting in multiple instances where residents waited extended periods for assistance. Observations and interviews revealed that several residents experienced significant delays, with one resident reporting waits of up to two hours and another stating they had to wheel themselves into the hallway and call out for help. Call light audit data confirmed numerous occasions where response times exceeded 15 minutes, with some instances surpassing an hour. These delays were corroborated by both resident interviews and electronic call light system records. Residents affected by these delays included individuals with significant care needs, such as a quadriplegic resident requiring assistance for all mobility and transfers, and another resident with a history of falls and incontinence who reported wetting herself due to long waits. The call light system audit showed repeated 'needs improvement' flags for response times in multiple rooms. Residents expressed feelings of degradation, abandonment, and distress due to the lack of timely assistance, and some had documented pressure ulcers or other conditions that made prompt response critical. Staff interviews indicated that the expectation was for call lights to be answered within three to five minutes, but this standard was not consistently met, especially after meal times or when staffing was low. There was confusion among staff regarding who was responsible for answering call lights, and the facility lacked a formal policy on call light response. Resident council meeting minutes and grievance records further documented ongoing concerns about long call light response times and perceived short staffing, indicating a persistent issue affecting resident care and satisfaction.