F0550

E

Failure to Ensure Timely and Effective Call Light Response for Multiple Residents

Flint, Michigan Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to timely response to call lights and basic care needs for multiple residents. One resident with heart failure, atrial fibrillation, COPD, and dependence on supplemental O2 experienced an oxygen concentrator malfunction and was placed on an oxygen tank that subsequently ran out. The resident developed a headache, dizziness, and lightheadedness, activated the call light, and waited approximately 25 minutes before staff responded. When staff did respond, they left the room to locate a full oxygen tank, placing the resident at serious risk of harm and demonstrating a failure to ensure basic medical safety and timely response.

Another resident with a history of femur fracture, muscle disorders, falls, and moderately impaired cognition (BIMS 9/15) was dependent on staff for toileting and lower body dressing. Confidential persons reported that this resident needed to use the bathroom, was not attended to, and was later found on the floor of another resident’s room with pants down below the knees. A confidential person also reported activating the call light during a visit and waiting more than 30 minutes with no staff response, ultimately taking the resident to the bathroom themselves. They reported that staff became upset and stated visitors should wait for staff, but the resident could not hold it that long, would try to get up alone, and had multiple incontinence episodes while waiting for staff. The confidential person also reported finding the resident incontinent of bowel and changing the resident themselves due to long response times.

A resident with stroke, diabetes, depression, and hemiplegia/hemiparesis, cognitively intact (BIMS 14/15) and dependent on staff for hygiene, toileting, bathing, dressing, mobility, and transfers, reported having a call light on for about 30 minutes with no staff entering the room. Observation showed the wall call light illuminated for the roommate, who denied activating it, while the resident’s own call light did not activate when pressed multiple times. Maintenance later adjusted the wall connection before the call light functioned. This resident reported that call light wait times could exceed 30 minutes and sometimes take up to an hour when calling for assistance after incontinence and for ice water.

Another cognitively intact resident (BIMS 15/15) with peripheral vascular disease, depression, diabetes, and a left above-knee amputation, dependent on staff for toileting, bathing, lower body dressing, and transfers, was observed with the call light on and reported needing to be changed and wanting a drink. The resident stated that sometimes the call light worked and sometimes it did not, and that staff would turn off the light, say they would return, and then not come back, sometimes resulting in waits longer than 30 minutes. Surveyors observed the call light above this resident’s door visible from the nurse’s station, with staff present in and around the area and using a nearby breakroom, while the call light remained unanswered. Housekeeping entered a nearby room first, and later a staff member entered the resident’s room, turned off the light, then went into the breakroom. The resident subsequently received a drink but had not been changed.

A further cognitively intact resident (BIMS 15/15) with anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental O2, dependent on staff for toileting, lower body dressing, mobility, and transfers, was observed with the call light on and reported that while it had not been on long at that moment, call light response times could be as long as an hour. Resident council minutes over several months documented repeated concerns that nursing call light response times were longer than normal or taking longer, with ongoing reports that call lights were not being answered timely. The ADON stated that call lights should be answered as soon as possible, within about 5 to 10 minutes, and that if a need was not met, the call light should remain on. Facility policy stated that call lights would be placed within residents’ reach and answered in a timely manner, and that staff should identify the location and answer promptly, turning off the light only if able to meet the resident’s request. Despite this, surveyor observations, resident interviews, and council notes showed ongoing delays, nonfunctioning or improperly connected call lights, and staff turning off call lights without meeting residents’ needs.