Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that residents' call lights were answered promptly for two of three sampled residents. For one resident with a history of falls, muscle weakness, fibromyalgia, and difficulty walking, observations showed that the call light was activated and audible for seven minutes while three staff members were present at the nursing station but did not respond. The resident later reported that she had pressed the call light about 20 minutes prior because she needed her morning medications, and that staff sometimes did not answer the call light at all. Her care plan required that the call light and personal items be kept within reach due to her high risk for falls and injury. Another resident, who was totally dependent on staff for activities of daily living and had a history of metabolic encephalopathy and falls, also experienced delayed response to the call light. The call light was observed to be active for eight minutes while two staff members were present at the nursing station but did not respond. Interviews with staff revealed that some were occupied with other tasks or were from the registry and did not respond to the call lights. Facility policy required all staff to promptly respond to activated call lights, regardless of their assignment or employment status.