F0550

E

Failure to Respond Timely to Call Lights Resulting in Prolonged Incontinence and Loss of Dignity

Grayville, Illinois Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to timely care and dignified treatment by not responding promptly to call lights, particularly on the North Hall. Multiple cognitively intact or moderately impaired residents who were dependent on staff for toileting and repositioning reported extended delays, often 30–60 minutes, before staff responded to their requests for assistance. These delays occurred despite care plan interventions that emphasized keeping call lights within reach and encouraging residents to use them for help, as well as documentation that several residents were incontinent and required extensive or total assistance with ADLs and toileting.

One resident with chronic respiratory failure, type 2 diabetes, morbid obesity, chronic kidney and heart disease, and a history of moisture-associated skin damage reported that on an evening shift she waited over 30 minutes for her call light to be answered, and that such delays of 30 minutes to an hour happened frequently, especially in the evenings. This resident was bedbound, dependent on staff for toileting and repositioning, always incontinent of bowel, and at risk for impaired skin integrity, yet she reported that often only one CNA was assigned to her hall and one CNA to the other hall. Another resident with Parkinson’s disease, COPD, panic disorder, and fibromyalgia, who required assistance with ADLs and was occasionally incontinent, stated she had to wait over an hour on an evening shift for her call light to be answered while lying in a soaked bed and feeling cold from being in her urine. She reported that when still in her wheelchair, she would sometimes wheel into the hall to look for staff because of the delays.

A third resident with permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes, unsteadiness on feet, and chronic pain, who was always incontinent and dependent for toileting hygiene, stated she had her call light on several times one night and had to wait 30–45 minutes each time for staff to respond, during which she lay in urine while waiting to be changed. A fourth resident with hemiplegia, type 2 diabetes, COPD, morbid obesity, neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, Parkinson’s disease, and multiple other comorbidities, who was always incontinent and dependent for toileting and transfers, reported being on her call light for over 30 minutes one night, even calling the nurses’ station for help, while waiting to be changed after an incontinent episode. She stated that such delays in the evening occurred often and that it could take 30–45 minutes, sometimes an hour, for call lights to be answered.

Surveyor observations and staff interviews corroborated these reports of delayed responses. On one evening, the DON stated that only two CNAs were working the floor, one CNA had called in, another had not shown up or called, and an agency nurse unfamiliar with the facility was the nurse on duty. The DON also stated another CNA was coming in later to help. During this time, the CNA assigned to the North Hall was observed taking residents outside to smoke, leaving no other CNA visible on that hall. Multiple call lights were observed activated in four separate rooms on the North Hall for an extended period while the CNA was outside and then occupied with other tasks, including taking vital signs on a resident in the dining room and answering the phone. An unknown resident was heard yelling for help from the North Hall while call lights continued to sound. The Administrator later stated he felt staff answered call lights in a timely manner but acknowledged that if only one CNA was on a hall, that CNA should not be taking residents out to smoke and leaving no staff on the hallway. The facility’s policy on answering call lights stated that the purpose of the procedure was to respond to residents’ requests and needs, but the observed and reported delays demonstrated a failure to follow this policy.