Failure to Provide Timely Call Light Response and Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary assistance with grooming and timely response to call lights. Record review showed that the resident, a female with multiple diagnoses including muscle weakness, gait abnormalities, lack of coordination, cognitive communication deficit, and end stage renal disease, required significant assistance. Interviews and documentation revealed that the resident experienced delays in care, specifically after a bowel movement when staff turned off her call light without providing the requested assistance, resulting in her remaining unclean until the following morning. Additional interviews with CNAs confirmed that call lights were sometimes turned off without care being provided, and residents expressed reluctance to use the call light due to fear of being ignored or inconveniencing staff. Staff interviews further indicated that call light response times were inconsistent, with some staff acknowledging that lights could remain unanswered for up to 15 minutes or more. The DON and Administrator confirmed that residents had complained about delayed responses and that there was no overnight manager on duty, relying instead on periodic spot checks by leadership. Review of grievance reports and facility policy corroborated that the expectation was for call lights to be answered as soon as possible, but this standard was not consistently met, resulting in unmet care needs for the resident.