Delayed Call Light Response and Resident Care
Penalty
Summary
Staff failed to answer a resident's call light in a timely manner, as observed when a call light and audible tone outside the resident's room went unanswered for approximately 27 minutes. The resident, who was admitted with diagnoses including a nondisplaced spiral fracture of the left tibia, COPD, diabetes mellitus, and schizophrenia, required maximum assistance with activities of daily living and had intact cognition. During the period of delay, the resident was found awake, fidgeting, and visibly uncomfortable, expressing frustration about having been left in a soiled diaper for more than five hours and requesting to be changed. A Certified Nurse Assistant (CNA) entered the room but did not provide care, stating she would notify the assigned CNA. The facility's policy, as confirmed by the Director of Nursing, required call lights to be answered within two minutes, and the written procedure indicated calls should be answered immediately. The delay in response was directly observed and confirmed through staff interviews and review of facility policy.