Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of two out of thirteen sampled residents by not ensuring that their call lights were answered in a timely manner. Observations revealed that for one resident with severe cognitive impairment who required substantial to maximum assistance with activities of daily living, the call light was activated and audible at the nurses station, but two staff members passed by the room without responding. The resident began screaming and was not assisted until 20 minutes later, when a CNA responded and confirmed the resident needed to be changed. In a separate incident, another resident activated the call light, which was also audible at the nurses station where two LVNs were present. An RNA passed by the room without responding, and the call light remained unanswered for 20 minutes until a CNA responded to remove the resident's lunch tray. Interviews with the involved staff confirmed they heard the call light but did not respond promptly, despite acknowledging that call lights should be answered right away. The facility's policy required prompt response to call lights, but this was not followed in these instances.