F0684

D

Failure to Timely Respond to Call Light for Dependent Resident on Floor Mat

Pharr, Texas Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with the resident’s person-centered care plan and professional standards of practice by not responding to a call light for an extended period. The resident involved was an older female with hemiplegia and hemiparesis affecting the left non-dominant side, contracture of the left hand, lack of coordination, schizoaffective disorder, and epilepsy. A quarterly MDS showed severe cognitive impairment with a BIMS score of 4, and Section GG documented that she was dependent or required substantial/maximal assistance for nearly all self-care and mobility tasks, including transfers and toileting. Her care plans identified ADL self-care performance deficits and risk for unmet needs, fall risk related to reduced mobility and hemiplegia with a history of falls, and behavior issues including throwing herself on the floor and sliding down to the mat. Interventions included keeping the bed in the lowest position, placing a floor mat next to the bed, ensuring the call light was within reach, and encouraging the resident to use the call light for assistance.

On the date of the incident, surveillance video from the resident’s room showed that at 4:37 a.m. she was lying in bed with her feet dangling off the side. At 4:43 a.m., she was observed sliding down from the left side of the bed into a sitting position on the floor mat and pressing the call light within eight seconds of reaching the floor. The wall-mounted call light was seen turned on and blinking. At 4:44 a.m., the resident was seen waving the call light in the air and placing it on top of the bed, and by 4:45 a.m. she had positioned herself lying on the floor. No video footage was available between 4:45 a.m. and 6:36 a.m. A second video segment with a timestamp of 6:36 a.m. showed a CNA entering the room, removing a blanket from the resident’s legs while she remained on the floor, and an LVN entering within about 10 seconds to check the resident. The family member’s own video, viewed by surveyors, similarly showed the resident sliding off the bed onto the mat, pressing the call light, and staff not entering the room until approximately two hours later.

Interviews with the resident and staff further described the delay in response to the call light. The resident reported that staff sometimes took a long time to answer her call light and that on this occasion she slid off the bed, sat on the mat, became dizzy, and remained on the floor for about an hour before staff helped her back to bed, though she stated she had no injuries. A family member stated that no one entered the room after the call light was pressed and that the camera in the room only recorded when there was movement, with video showing the resident sliding to the floor and pressing the call light, and a later clip showing staff entering the room roughly two hours afterward. Multiple staff interviews revealed that the call light system required staff to physically enter the room to turn off the light and that there was no electronic log of call light duration. Staff accounts indicated that the resident’s room had been noted as “pending to be seen,” that some staff saw or believed they saw the call light on but did not enter the room, and that staffing on the unit was reduced due to call-ins and a no-call/no-show on the overnight shift. Collectively, these observations and statements show that the resident’s call light remained unanswered for approximately 1 hour and 45 minutes while she was on the floor, contrary to her care plan interventions and the facility’s call light response policy.