Failure to Provide Dignified Care Due to Inadequate Call Light Response
Penalty
Summary
The facility failed to provide a dignified living existence for three residents by not ensuring that call lights were used appropriately to meet residents' needs. Staff responded to call lights in a timely manner but would turn off the call lights without providing the requested assistance, resulting in residents not receiving necessary help with toileting and personal care. This led to two residents soiling themselves and another resident, who was non-weight bearing, attempting to transfer herself to the bathroom, contrary to her care plan and safety instructions. One resident, who was cognitively intact and required substantial assistance with toileting due to multiple medical conditions including diabetes, morbid obesity, and lymphedema, reported that her call light was answered and turned off without assistance being provided, causing her to soil herself and develop a macerated area on her skin. Another resident, also cognitively intact and with a non-weight bearing status due to a hip fracture, reported having to self-transfer to the toilet because staff would answer the call light but not return to assist her, despite being instructed not to bear weight or transfer independently. A third resident, with a history of cancer and chronic illness, reported soiling herself while waiting for staff to return after answering her call light, resulting in soiled clothing and discomfort. Interviews with staff revealed that some nursing assistants would turn off call lights upon entering the room to keep response times low, with the intention of returning later, but sometimes forgot to return. The nurse manager and DON were not aware of this practice and stated that the facility's policy was to not turn off the call light until the resident's needs were met. The facility's dignity policy emphasized care that promotes well-being and self-worth, which was not upheld in these instances.