Failure to Ensure Timely Response to Call Light for Resident with Behavioral Care Plan
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodations for her needs, specifically regarding timely response to her call light. The resident, a cognitively intact female with diagnoses including cerebral edema, chronic respiratory failure with hypoxia, diabetes, and acute kidney failure, required partial to moderate assistance with toileting hygiene and was dependent for toilet transfers. On the date in question, the resident reported that she pressed her call light multiple times and waited approximately 15 minutes without a response, leading her to call 911 for assistance. Police responded to her call and spoke with both the resident and facility staff. Interviews with staff revealed that the resident was known for frequent use of the call light and for changing her mind about care needs shortly after declining assistance. Staff described repeated entries into her room to address her requests, and noted that she was care-planned for behaviors such as making false allegations and requesting continuous staff presence. On the day of the incident, staff recounted that the resident refused care from one CNA, requested another, and then refused that CNA as well, before eventually allowing the original CNA to return. During this time, the police arrived in response to her 911 call. Facility records and staff interviews indicated that the resident had a history of making allegations about delayed or refused care, and her care plan included interventions for these behaviors. The facility's policy required call lights to be answered within five minutes, but the resident reported a significantly longer wait time. Staff and administration acknowledged the resident's behavioral patterns and the ongoing investigation into her grievance, but the deficiency centered on the failure to ensure timely response to her call light as required by facility policy.