Ongoing Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner for multiple residents, despite a policy directing staff to respond to resident calls as soon as possible. Interviews and record reviews showed that six residents, several of whom were cognitively intact and required assistance with activities of daily living such as toileting, hygiene, dressing, and transfers, reported frequent and prolonged delays in call light response. One resident who uses a wheelchair and needs substantial/maximal assistance stated that call lights are typically unanswered for at least 30 minutes or more and that this concern is repeatedly raised at Resident Council meetings without improvement. Another cognitively intact resident who can perform most tasks independently reported that residents regularly complain that staff are on their phones, do not want to work, and fail to answer call lights. Additional residents with moderate cognitive impairment and functional limitations described waiting long periods for toileting assistance, including one resident who reported feeling embarrassed after wetting the bed because staff did not respond quickly enough to the call light. Another wheelchair-bound resident needing partial to moderate assistance with ADLs stated it was not uncommon to wait about forty minutes, especially at night, for staff to respond. Other residents reported that staff “do not want to work” and that call lights are often unanswered for an hour or more, causing stress when help is needed. The Ombudsman confirmed receiving numerous complaints and making several visits regarding delayed call light response, noting the problem persisted. Resident Council minutes and written grievances over several months documented repeated reports of call lights remaining on for over an hour on all shifts, staff sitting at the desk while call lights and doorbells rang, and concerns that nurses were not assisting CNAs with answering call lights. The DON acknowledged awareness of some complaints and stated an expectation that call lights be answered within 10–15 minutes, while the written policy required answering resident calls as soon as possible.
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