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F0919
E

Delayed Call Light Response for Residents Requiring Assistance

Duarte, California Survey Completed on 12-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call lights were answered immediately for two of three sampled residents. One resident, admitted with a right humerus fracture and a history of falls, required maximal assistance for mobility and was dependent for certain movements. The resident's family member reported that staff sometimes took up to an hour to respond to call lights, leading the family member to assist the resident with bathroom needs when staff were delayed. Another resident, admitted with a spinal fusion and muscle weakness, reported two separate incidents where it took staff an hour to respond to the call light, both during the day and at night. The resident stated that on those occasions, no staff came to check on their needs, which typically involved assistance to the bathroom. Interviews with facility staff, including a CNA and an LVN, confirmed that call lights are expected to be answered immediately due to the potential for emergencies. Resident Council Meeting minutes from two separate dates indicated ongoing concerns from residents about untimely responses to call lights, particularly during the overnight shift, and instances where residents' needs were not met even when call lights were answered. The facility's policy requires immediate response to call lights and completion of requests within five minutes if possible, but this standard was not consistently met as evidenced by resident and family reports.

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