Failure to Respond Timely to Resident Call Light for Dependent Personal Care
Penalty
Summary
Staff failed to respond in a timely manner to a resident who required assistance with activities of daily living, specifically with changing briefs due to urinary and bowel incontinence. The resident activated her call light, which remained on for over four hours, and multiple staff members entered her room but did not provide the needed personal care or turn off the call light. The resident ultimately contacted a family member for help, who, after being unable to reach the facility, called the local police to conduct a welfare check. Interviews with staff revealed that shift change communication was lacking, as incoming staff were not informed of the resident's need for assistance. Staff prioritized other residents based on perceived urgency and did not follow through with the resident's request, despite being aware of her call light. Documentation showed that staff were instructed to leave call lights on until all resident needs were met, but this led to confusion and further delay in care. The resident was dependent on staff for toileting and hygiene, as indicated by her care plan and assessment, and had a history of urinary and bowel incontinence. Despite being checked on earlier in the day, her needs were not met during the evening shift, resulting in an extended period without necessary personal care. Facility records confirmed the prolonged call light response time and the lack of timely assistance provided to the resident.