Failure to Protect Resident from Neglect Due to Delayed Call Light Response
Penalty
Summary
A resident with multiple medical conditions, including mixed incontinence, an open wound on the right buttock, spinal stenosis, morbid obesity, and mental health diagnoses, experienced prolonged wait times for staff response to call lights. The resident, who was bedfast and had a history of refusing some care, reported several instances where call lights were not answered for periods ranging from over 20 minutes to more than an hour. During these times, the resident was left incontinent of urine or bowel, which contributed to feelings of humiliation and discomfort. Documentation confirmed that the resident's call light was left unanswered for extended periods on multiple occasions, as evidenced by the facility's call light log and the resident's own statements during interviews. The resident's care plan indicated a need for significant assistance, including daily wound care and regular toileting, due to his risk for skin breakdown and incontinence. Despite these needs, staff interviews revealed inconsistent expectations regarding timely call light response, with some staff expecting a two-minute response and others considering 20 to 30 minutes as prompt. The resident's medical record also showed a Braden score indicating mild risk for skin breakdown and a BIMS score reflecting intact cognition, supporting the resident's ability to accurately report his experiences. Facility policies required prompt response to call lights and protection from neglect, but the documented delays in responding to the resident's requests for assistance resulted in the resident remaining in soiled conditions for extended periods. Staff interviews acknowledged the resident's distress and the impact of delayed care, while administrative staff provided varying definitions of what constituted an appropriate response time. These actions and inactions led to the resident experiencing neglect, as defined by the facility's own policies and regulatory standards.