Delayed Response to Alternative Call Lights Resulting in Loss of Dignity
Penalty
Summary
The facility failed to answer alternative call lights for residents needing assistance in a timely manner, resulting in a lack of dignity for several residents. The call light system on three halls had been nonfunctional since the end of August, and residents were provided with alternative devices such as bike horns, whistles, and bells to signal for help. Multiple residents reported that these devices were often ineffective, as staff had difficulty hearing or locating the source of the sound, especially when residents were at the end of the hall or had their doors closed. Staff interviews confirmed these challenges, noting that it was hard to determine which resident needed help and that response times were delayed as a result. Several residents with significant medical needs, including those with mobility impairments, overactive bladder, and cognitive limitations, experienced incontinence episodes while waiting for assistance. These residents described feelings of humiliation, embarrassment, and shame as they were left to sit in their own urine or feces until staff could respond. Some residents reported that they had to rely on their roommates to signal for help, and in some cases, staff discouraged this practice. Residents also expressed frustration with the alternative call system, stating that it was unreliable and did not meet their needs for timely assistance. Staff interviews corroborated the residents' accounts, acknowledging that the alternative devices were difficult to hear and that it often took longer to respond to residents' needs. Staff described having to walk down halls and call out to identify which resident was signaling for help, further delaying response times. The facility did not have documentation of any increased monitoring, such as 15-minute checks, and there was no policy on dignity. The facility's existing call light policy required functioning call lights, which were not available on the affected halls during the period in question.