Delayed Call Light Response and Inadequate ADL Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide timely assistance for activities of daily living (ADLs) to eight out of sixteen sampled residents. Multiple residents experienced prolonged call light response times, with documented waits ranging from 15 to 57 minutes. These delays resulted in residents waiting to be assisted to bed, experiencing incontinence, and feeling embarrassment or stress. In several cases, staff turned off call lights without addressing the residents' needs, requiring residents to reactivate their call lights or wait even longer for assistance. Residents and their roommates confirmed these occurrences during interviews, and staff interviews corroborated that call light response times were often lengthy, especially during busy periods or when the facility was short-staffed. The facility's own policies require that all staff respond to activated call lights and that residents receive necessary services to maintain their abilities in ADLs. Despite these policies, staff interviews revealed that call lights were sometimes turned off without providing the requested assistance, and residents were told they could not go to bed at their preferred times. Staff described having routines for putting residents to bed and sometimes delaying assistance based on their own schedules rather than residents' needs. Several staff members acknowledged that staffing shortages contributed to the delays, and that response times could be as long as 20 minutes or more, particularly during shift changes or peak times. Medical records and Minimum Data Set (MDS) assessments indicated that the affected residents had significant physical and cognitive needs, including total dependence on staff for bathing, toileting, and transfers. The delays in responding to call lights led to increased incontinence, embarrassment, and stress for these residents. The facility's grievance log and call light audits further substantiated the pattern of delayed responses, with multiple instances of call lights remaining unanswered for extended periods. Facility leadership acknowledged that staff should not turn off call lights without meeting residents' needs and that communication among staff should be used to ensure timely assistance, but also indicated that a 15-minute response time was considered acceptable during busy times.