Failure to Ensure Call Light Accessibility and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, both of whom required assistance with activities of daily living. One resident, who was dependent for toileting hygiene and bathing due to diagnoses including dysphagia and heart failure, was observed lying in bed with the call light placed behind the bed, out of reach. The resident's incontinence brief was found to be wet and soiled, and staff acknowledged that it had been that way since the previous shift. The certified nurse assistant (CNA) responsible stated she had intended to change the resident after breakfast but was delayed due to attending to other residents. Another resident, who required supervision or touching assistance for personal care due to diagnoses including type 2 diabetes mellitus and atrial fibrillation, was also found lying in bed with the call light out of reach. This resident's incontinence brief was similarly observed to be wet and soiled. The CNA assigned to this resident stated that she had not yet rounded on the resident because she was distributing breakfast trays and assisting with feeding. The resident reported feeling neglected and uncomfortable due to prolonged periods without staff checking on her or changing her brief. Interviews with staff, including a licensed vocational nurse (LVN) and the director of nursing (DON), confirmed that call lights are expected to be within reach at all times to allow residents to request assistance promptly. Facility policy also requires call lights to be accessible from the bed and other locations. Staff acknowledged that failure to provide timely incontinence care and to ensure call light accessibility could result in residents remaining unattended and in soiled conditions for extended periods, compromising their dignity and delaying care.