F0919

E

Failure to Ensure Accessible Call Lights and Timely Response to Resident Requests

Panama City, Florida Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to ensure that the call light system was accessible to dependent residents in their rooms and bathrooms, as required by facility policy. During a tour on 02/23/26, multiple rooms were observed where call lights were not within reach of residents lying in bed. Examples included call lights fastened with clips between the bed and bedside dresser, wrapped around wheelchair handles near the floor, hanging on the wall, clipped to privacy curtains, or lying on the floor at the head or side of the bed, all out of reach of the residents. Photographic evidence was obtained of these call light placements.

Additional observations on the 300 hallway showed a call light activated and beeping for an extended period while several staff members sat at the nurses’ station, a nurse stood at the end of the hallway near the medication cart, and multiple staff walked past the room without responding. The call light remained unanswered for at least 15 minutes before the nurse at the end of the hallway acknowledged the light and stated she was trying to finish other tasks before entering the room, explaining that the resident wanted her phone plugged in to charge. On 02/24/26, a follow-up tour again found call lights in several rooms lying on the floor out of reach of residents who were in bed.

Resident interviews corroborated these observations. One resident reported pressing the call light and sometimes having no one respond, or staff entering the room, turning off the call light, stating they would return, and then not coming back; this resident described sitting in the hallway or at the nurses’ station to obtain assistance and reported seeing staff on their phones playing games, with call light response times reported as over 30 minutes and sometimes up to an hour. Another resident stated that staff sometimes did not come when the call light was turned on and that, when they did respond, it was too late and the resident had already soiled themselves. A third resident reported waiting to be changed after pressing the call light, stating that response times depended on the time of day and were usually more than 30–45 minutes. Review of resident council grievances over three consecutive months showed repeated complaints about staff being on phones in the hallway, call lights not being answered in a timely manner, and residents not being changed promptly after incontinence episodes. The DON acknowledged multiple grievances regarding delayed call light response and untimely care and described expectations that care be provided every two hours and as needed, and that call lights be answered within 5–10 minutes, but could not provide documentation of formal training related to these issues.