Failure to Address Grievances Regarding Delayed Call Light Response
Penalty
Summary
The facility failed to follow up on grievances related to call light response times for two residents who required substantial assistance for mobility, transfers, and toileting due to conditions such as paraplegia, neuromuscular dysfunction, and multiple sclerosis. Both residents were dependent on staff for bed mobility and transfers using a mechanical lift, and their care plans identified them as high risk for pressure injuries and self-care deficits. Despite these needs, documented grievances and interviews revealed that call lights were not being answered in a timely manner, with multiple instances of response times exceeding one hour. Facility grievance forms and call light logs showed repeated concerns about long wait times for call light responses, particularly during morning and afternoon shifts. Staff interviews confirmed that call lights for these residents, who required two-person assistance, were often delayed due to staffing shortages and prioritization of other units. The logs documented numerous occasions where call lights remained unanswered for over an hour, and both residents reported experiencing significant delays in receiving assistance for their care needs. Interviews with staff indicated that monitoring systems were in place, but response times were still prolonged, especially for residents outside the secured dementia unit. The facility was unable to provide a policy related to call light response when requested. The lack of prompt response to call lights and insufficient follow-up on grievances demonstrated a failure to honor residents' rights to voice grievances without discrimination or reprisal and to make prompt efforts to resolve those grievances.