Failure to Provide Adequate Supervision and Timely Call Light Response Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and progressive neurological conditions. The resident required partial to moderate assistance with mobility and activities of daily living, including transfers and toileting. On the day of the incident, the resident fell in the bathroom after attempting to use the toilet without assistance, resulting in a head injury and an abrasion to the left elbow. The fall was unwitnessed, and the resident was found on the floor by a CNA after the emergency bathroom call light had been activated for an extended period. Medical record review and staff interviews revealed that the resident had previously reported delays in staff response to call lights, sometimes waiting over 20 minutes, which led the resident to attempt bathroom use independently. On the day of the fall, the emergency bathroom call light was activated and remained unanswered for 36 minutes before being cancelled. The CNA who found the resident was unfamiliar with the resident and had been told the resident was fairly independent. The RN who responded noted that the resident did not normally use the call light and that no alarms were heard at the time of the incident. Further investigation showed that the call light system in use at the time did not differentiate between emergency and regular calls, as both had the same tone, making it difficult for staff to prioritize responses. The administrator confirmed that staff were expected to answer call lights immediately, but the system's limitations and staff unfamiliarity contributed to the delayed response. As a result of the fall, the resident developed a subdural hematoma and subsequently passed away.