Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for five out of 46 residents, resulting in prolonged wait times for assistance. Multiple residents reported and were observed experiencing significant delays, with call light response times documented as exceeding 20 minutes on several occasions, and in some cases, reaching up to 45 minutes. Staff interviews confirmed that call lights were not always answered promptly, particularly during periods of short staffing or when staff were engaged in other duties such as passing meal trays. Observations revealed that staff sometimes walked past illuminated call lights without responding, and that there was no pager system in place to alert staff to active call lights outside of the nurses' station. Residents affected by these delays included individuals with various medical conditions such as femur fracture, asthma, muscle weakness, urinary tract infection, chronic kidney disease, diabetes, sepsis, prostate cancer, repeated falls, end stage renal disease, and others. Some residents were cognitively intact, while others had moderate cognitive impairment. Residents described waiting over an hour for assistance, including instances where they remained in soiled conditions due to incontinence until staff responded. Call light data reports corroborated these accounts, showing multiple instances of extended response times across different dates and shifts. Staff interviews indicated that the unit was often staffed with only one CNA, which was insufficient to meet the needs of residents with high medical acuity and complex care requirements. Staff acknowledged that all personnel were expected to respond to call lights, but this expectation was not consistently met. The DON stated that response times exceeding 20 minutes were not acceptable, yet documented response times frequently surpassed this threshold. Resident Council notes further reflected resident concerns about insufficient staff assistance and infrequent rounding.