Failure to Promptly Respond to Call Lights and Toileting Requests
Penalty
Summary
Facility staff failed to promptly respond to call lights and requests for toileting assistance for three of five sampled residents, as required by the facility's policy on dignity. One resident with severe cognitive impairment and significant assistance needs for toileting and hygiene was reported by a family member to experience long delays in staff response, often requiring the family member to seek help directly from the nurses' station. Another resident, who was incontinent and at risk for skin breakdown, reported waiting up to 30 minutes or more for assistance after activating the call light, including a specific incident where the resident waited a total of three hours to be changed after an incontinent episode. This resident described feeling ignored and demeaned by the delays. Observations confirmed that call lights remained on for extended periods before staff responded. In one instance, a resident waited 30 minutes for help with a soiled brief, and in another, a resident waited for assistance after an episode of incontinence, with staff not returning as promised. Interviews with residents revealed that these delays were not isolated incidents, with reports of waiting hours for assistance, particularly during nighttime hours. Residents expressed feelings of frustration and a lack of dignity due to these prolonged waits. Staff interviews corroborated that residents should not have to wait long for assistance, especially when in need of changing soiled briefs. The Director of Nursing stated that residents should not wait longer than five minutes for such assistance to maintain their dignity, as outlined in the facility's policy. The policy specifically prohibits practices that compromise dignity and requires prompt response to toileting requests, which was not consistently followed in these cases.