Failure to Respond Timely to Call Light for Dependent Resident
Penalty
Summary
The facility failed to provide timely responses to a resident's call light, resulting in significant delays in assistance for a resident who was completely dependent on staff for all activities of daily living due to quadriplegia and other medical conditions. The resident, who had intact cognition, required total staff assistance for hygiene, mobility, toileting, and other care needs. Upon admission, the resident initially had to use a cell phone as a call light, which was unreliable due to battery and accessibility issues. After eight days, the facility provided a motion sensor doorbell system as a call light, but this system only rang once in the common area and was not consistently audible to staff, especially when they were in other rooms or down the hallway. Multiple documented instances showed that the resident's call light went unanswered for periods ranging from 15 minutes to over an hour. Observations confirmed that after activating the motion sensor call system, staff did not respond within a reasonable timeframe. Staff interviews corroborated these findings, with several staff members reporting that high resident acuity and insufficient staffing levels made it difficult to answer call lights promptly. Staff also noted challenges in distinguishing between different residents' doorbell systems and hearing the alerts when not in the immediate area. Facility policies required timely responses to call lights and sufficient staffing based on resident needs and acuity. However, both staff and the resident reported ongoing issues with the call light system's effectiveness and the facility's ability to meet response time expectations. The Director of Nursing and the administrator acknowledged the resident's concerns and the limitations of the current call light system, as well as the challenges posed by staffing levels and resident acuity.