Delayed Call Light Response Leads to Resident Incontinence and Loss of Dignity
Penalty
Summary
A deficiency occurred when the facility failed to respond to a resident's requests for assistance in a timely manner, resulting in the resident experiencing incontinence episodes. The resident, who was cognitively intact and dependent on staff for toileting and other activities of daily living due to multiple medical conditions including morbid obesity, spinal stenosis, and muscle weakness, reported having to urinate on herself on several occasions. These incidents were specifically noted to occur during night shifts and weekends when staffing levels were lower than during the day. The resident expressed feelings of discomfort, anxiety, humiliation, and embarrassment as a result of these events. Documentation from resident council meetings and grievance forms indicated ongoing concerns about insufficient CNA staffing at night, with repeated complaints from the resident and her family about delayed call light responses and unmet needs such as assistance with toileting and obtaining ice water. The resident and her family reported multiple instances where the call light was left unanswered for extended periods, sometimes over an hour, leading to incontinence. Staff interviews corroborated these accounts, with CNAs and nurses acknowledging that short staffing, particularly on weekends and during busy evening hours, made it difficult to respond promptly to call lights, especially for residents requiring two-person assistance. Facility leadership and staff confirmed that there were frequent staffing shortages, especially when scheduled CNAs called in and were not replaced. The facility's census showed a significant number of residents requiring two-person assistance, further straining available staff. Staff reported that management was aware of the issue, and that the problem was exacerbated by additional duties such as laundry falling to night shift staff. The facility's own policy emphasized the right of residents to be treated with respect and dignity, which was not upheld in these instances.