Delayed Call Light Response Resulting in Prolonged Exposure to Soiled Brief
Penalty
Summary
The facility failed to ensure that a resident's call light was answered in a timely manner, resulting in the resident waiting for two hours in a soiled brief during the night shift. The resident, who was alert, oriented, and cognitively intact with a BIMS score of 15, was fully dependent on staff for toileting hygiene according to the Minimum Data Set. The resident reported feeling frustrated and depressed due to the prolonged wait, and verified the duration using her cell phone. A CNA working the night shift confirmed that call lights may not have been answered promptly, despite having no reported staffing issues and being responsible for 12-14 residents. Facility policy required nursing staff to answer call bells promptly and courteously.