F0550

E

Failure to Ensure Accessible Call Lights, Timely Responses, and Dignified Interactions

Grand Blanc, Michigan Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, communication, and timely assistance by not ensuring call lights were accessible and responded to promptly. One resident with chronic obstructive pulmonary disease, chronic pain, respiratory failure, a history of falls, and intact cognition reported that when she activated her call light, it sometimes took 30 minutes to an hour for staff to respond, especially at night. She stated that this delay also affected her ability to receive pain medication, as she first had to wait for staff to answer the call light and then wait longer to actually receive the medication. Another resident with intact cognition who required substantial/maximal assistance with toilet transfers and toileting hygiene reported being left on the toilet for about 30 minutes and stated that he sometimes had to wait more than 30 minutes for assistance, mostly on night shift. He described that nurses would answer the call light, turn it off, say they would notify someone, and then not return, requiring him to turn the call light back on after about 10 minutes when no one came.

The facility also failed to ensure that call lights were consistently within reach for several residents with significant functional and cognitive impairments. One resident with moderately impaired cognition who required substantial/maximal assistance with personal hygiene, rolling, and was dependent for transfers, dressing, and toileting was observed lying in bed with the bed in a high position and the call light placed on a Geri chair, covered by items, and out of his sight and reach. He reported that the call light often fell on the floor and that he resorted to throwing objects at the door to get staff attention. A nurse, when alerted, acknowledged that the resident should have had the call light in reach and then repositioned it and lowered the bed. Another resident with severe cognitive impairment, hemiplegia and hemiparesis, muscle wasting, atrophy, and attention and concentration deficits was observed with the call light lying on the floor at the head of the bed and not within reach; a CNA confirmed it should not have been on the floor and then clipped it to the resident’s blanket. The resident’s care plan specifically included an intervention to place the call light within reach.

Additional concerns were identified through a confidential group meeting with residents and a family member, as well as with a resident dependent on a ventilator. The group reported that they all wait a long time for call lights to be answered and that staff often enter the room, turn off the call light without completing the requested task, or say they will return and do not, then become upset if residents turn the call light back on. The group also agreed that call lights are frequently on the floor or out of reach. They reported that staff have personal conversations that can be overheard, talk about other residents or their own personal lives, and talk to each other rather than to the resident while providing care, and that staff sometimes visit in rooms instead of completing tasks timely. A family member stated she has had to call the facility to get help for her brother, who needs suctioning and cannot reach his call light, particularly on weekends or after 7:00 p.m. Another resident with chronic respiratory failure, ventilator dependence, muscular dystrophy, and limited use of his hands reported that his press-pad call light, designed to be activated by his head, is sometimes out of reach, forcing him to yell for help. The unit manager stated that call lights should be answered as soon as they go off and should be clipped within residents’ reach, indicating a discrepancy between facility expectations and observed practice.