Failure to Respond Promptly to Call Light Resulting in Undignified Treatment
Penalty
Summary
The deficiency involves a failure to treat a resident in a dignified manner by not responding promptly to the resident’s call light. The resident, who had diagnoses including type 2 diabetes mellitus, acute arterial ischemic stroke, bipolar I disorder with psychotic features, and schizophrenia, was cognitively intact and required varying levels of staff assistance for activities of daily living, including being dependent for toileting hygiene and bathing. The resident’s admission care plan did not include a focus area for behaviors. During a continuous observation on 02/16/26 from 11:10 AM to 11:31 AM, the resident’s call light remained on while he repeatedly yelled for assistance, stating, “Hey, someone help me, hey come here, I need help.” At approximately 11:16 AM, the surveyor informed the resident they would get assistance, and a nursing assistant in the adjacent room stated she would get to him as soon as possible, but the resident continued to yell out without receiving help. By approximately 11:30 AM, the surveyor went to the nurses’ station where five staff members (a medication aide, a human resource coordinator/NA, a nurse, and two NAs) were present. The staff acknowledged that the call bell was on but did not know how long it had been activated, even though the call light was visible and audible at the beginning of the hall near the nurses’ station. When the surveyor asked if they assisted with answering call lights, the medication aide initially responded that the resident “does that, he yells out for assistance” and did not go to assist him; the nurse and two NAs did not respond to the surveyor’s repeated questions. The human resource coordinator/NA then approached to assist the resident. In an interview, the resident reported he had been yelling for about 30 minutes with no response, stated he tracked the time using his television, and said this delay occurred frequently, sometimes up to an hour or more, regardless of his needs. He stated this made him upset and frustrated. In a separate interview, the DON reported she was unaware of the wait times and staff not answering this resident’s call bell, acknowledged the resident’s mental health conditions could affect his sense of time, and stated her expectation was that all staff answer call lights.
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