Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to answer call lights in a timely manner for one of three sampled residents reviewed for call light response. Call light logs revealed multiple instances where the resident's call light remained active for extended periods, including durations of over an hour and, in one case, more than three hours. Documentation showed that the resident had to call out for help and was found on the bathroom floor after attempting to get assistance for an extended period. The resident reported having to wait 15 to 45 minutes on several occasions for staff to respond to their call light, sometimes resorting to calling the security desk for help at night. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including heart failure, hypertension, and renal insufficiency. The resident required substantial to maximum assistance with activities of daily living, including transfers and toileting, and was considered a fall risk. Despite these needs, the resident reported being left unattended on the toilet for at least 30 minutes, leading them to slide to the floor and crawl toward the door to seek help. Staff interviews confirmed that call light response times varied, with some staff indicating that response times could be longer during busy periods such as mealtimes. Interviews with facility staff, including the DON, LPNs, and CNAs, revealed inconsistencies in the expected and actual response times to call lights. While some staff stated that the expected response time was two minutes, others considered up to 15 minutes to be timely, especially during busy periods. The DON acknowledged that call light response times were monitored only randomly or in response to complaints and that there were issues with staff acknowledging but not turning off call lights, which could affect the accuracy of response time records.