Failure to Ensure Functioning Call Lights and Timely Responses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had functioning call lights and timely responses to call light use, resulting in residents being left in soiled conditions and on bedpans for extended periods. One resident with hypertension, prediabetes, and post-polio syndrome, who was cognitively intact and required substantial/maximal assistance for toileting, reported being incontinent twice and left sitting in feces for over two hours on both occasions after being told staff were too busy serving supper. This resident also reported being left on a bedpan for more than an hour on more than one occasion, experiencing call light response times of up to an hour, and additional delays of up to another hour before a nurse arrived. The resident stated that staff sometimes entered, turned off the call light, and did not return. Another cognitively intact resident with type 2 diabetes and fractures of the left tibia and fibula, who required partial to moderate assistance for toileting, reported that her call light had not been working for 3–4 days. Observation confirmed that when she pressed the call light button, the corridor light did not illuminate. The resident stated that while day shift staff checked on her more frequently due to the nonfunctioning call light, night shift staff did not, and she had to yell for help during the night, including one occasion when she hollered for about 30 minutes before anyone came, despite hearing staff talking nearby. She reported being left in her own urine for an extended period in an undignified manner. Staff interviews showed inconsistent awareness of how long the call light had been nonfunctional, and resident council feedback documented complaints over the past 90 days that call lights could take up to an hour to be answered, contrary to the facility’s written policy requiring timely response and continuous availability of call lights to residents able to use them.
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