Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and respect by not ensuring timely responses to call lights, as required by their own policy. Multiple residents reported excessive wait times for assistance after activating their call lights, with some waiting up to two or three hours, particularly during night shifts and weekends. These delays were corroborated by resident interviews, a frequent visitor, and grievance records, all indicating that long response times were a persistent issue. Residents expressed feelings of frustration, anxiety, and distress due to these delays, especially when assistance was needed for toileting, mobility, or after falls. One resident described being left in soiled briefs for extended periods, resulting in skin irritation and emotional distress. Another resident recounted waiting up to two hours for help, and a third reported a fall where assistance did not arrive for thirty minutes. Grievance forms and interviews revealed that residents had repeatedly raised concerns about call light response times, both individually and through the resident council, but the issue persisted. Staff interviews confirmed that call light response times were often prolonged, especially when staffing levels were inadequate due to call-outs or insufficient coverage during certain shifts. Facility records showed that call light audits were conducted, but these were limited to daytime hours and did not address the periods when residents reported the longest delays. The audits and grievance documentation further substantiated that call lights were not consistently answered within the facility's policy timeframe. Despite staff education and some interventions, the deficiency remained evident through ongoing resident complaints, documented grievances, and audit findings.