Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were answered in a timely manner, as required by facility policy. Resident 4, who had systemic lupus erythematosus, pain from orthopedic devices, generalized muscle weakness, and partial traumatic amputation of both feet, was dependent on staff for mobility and toileting. Resident 4 reported that it often took twenty to thirty minutes for staff to respond to call lights, resulting in prolonged periods of being wet and soiled, which exacerbated pain and discomfort. Resident 4 stated that despite raising concerns with staff, the issue persisted. Resident 5, diagnosed with cardiomyopathy, hypertension, and anxiety disorder, was also dependent on staff for transfers and mobility. Resident 5 reported frequent delays in call light response, particularly at night, and expressed feelings of neglect after complaints to the night shift charge nurse did not resolve the issue. Interviews with CNAs confirmed that residents commonly complained about delayed call light responses, especially during shift changes or when staffing was reduced due to call-outs. The DON acknowledged that facility policy required immediate or prompt response to call lights, and that call lights were the primary means for residents to request assistance.