Delayed Call Light Response and Inaccessible Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights and did not ensure call lights were within reach for certain residents. Resident council minutes documented ongoing concerns about delayed call light responses, with residents reporting that response times often exceeded the facility's standard of 15 minutes, particularly during the night shift when waits could reach up to 40 minutes. Interviews with cognitively intact residents confirmed these delays, and the Director of Nursing acknowledged the expectation for call lights to be answered within 15 minutes. Additionally, observations revealed that two residents with significant physical and cognitive impairments did not have their call lights within reach for extended periods. One resident, dependent on staff for transfers and toileting due to hemiplegia and dementia, was observed unable to access the call light, which was placed approximately five feet away. Another resident with muscular dystrophy, respiratory failure, and a tracheostomy was observed in bed for over two hours with the call light on the floor, out of reach, despite multiple staff entering the room during that time. Facility policy requires call lights to be accessible to all residents, but this was not consistently followed.