Failure to Respond Timely to Resident Call Bell
Penalty
Summary
Facility staff failed to provide a reasonable accommodation of needs for one resident by not responding to the resident's call bell in a timely manner. The resident, who had diagnoses including chronic obstructive pulmonary disease, dysphagia, and major depressive disorder, was cognitively intact according to the most recent assessment. The resident reported to the surveyor that call bell response times had been an ongoing issue, discussed at resident council meetings without improvement, and stated they had waited up to an hour for assistance in the past. During the surveyor's visit, the resident's call bell had been on for about five minutes, and the surveyor observed the call light active over the resident's door. Multiple staff were present at the nurse's station and walked by the resident's room without acknowledging the call bell, which remained unanswered for at least 20 minutes. Facility leadership, including the ADON and DON, provided differing expectations for call bell response times, with the ADON stating approximately five minutes and the DON stating 20 minutes or less. The facility's policy on answering call lights did not define a specific response time but emphasized that any staff member could answer a call light and that response should be appropriate to the situation. Despite these guidelines, staff failed to respond to the resident's call bell in a timely manner, as observed by the surveyor and confirmed through staff and resident interviews.