Failure to Provide Timely Incontinence Care Due to Call Light System Malfunction
Penalty
Summary
A resident with diagnoses including congestive heart failure, dementia, anxiety, and depression, who was dependent on staff for toileting, did not receive timely incontinence care. The resident's care plan required staff to check for incontinence every two hours and to change the adult brief as needed. On the day of the incident, the resident activated her call light and waited for assistance for an hour and a half without response. During this time, she attempted to get up on her own, resulting in incontinence episodes in both her bed and wheelchair. Observations confirmed that her bed pad, adult brief, gown, and wheelchair cushion were saturated with urine, and both the call lights in her room and bathroom were still on. Staff interviews revealed that CNAs were unaware the resident's call light was on, as they were occupied with other duties such as passing breakfast trays and assisting with showers. Additionally, the call light bar in the hallway, which displays active call lights and room numbers, was malfunctioning and intermittently failed to show which rooms required assistance, instead displaying only flashing asterisks. The Assistant Director of Nursing confirmed the call light system was not functioning correctly and acknowledged that the resident waited an excessive amount of time for assistance.