Failure to Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.