Untimely Response to Call Light Leads to Incontinence Episode
Penalty
Summary
The facility failed to provide timely incontinence and toileting care to Resident #2, who had diagnoses including lumbar spondylosis, diabetes, and hypertension, and was care planned for self-care deficits related to weakness and limited mobility. The resident’s care plan and MDS documented bladder incontinence, frequent bowel and bladder incontinence, dependence with toileting, and the need for staff assistance with hygiene and transfers, including one staff participation with toileting and checking the resident as required for incontinence. Despite these identified needs, the electronic call light system at the nurse’s station showed Resident #2’s call light active and unanswered for at least 35 minutes while two staff members were seated at the nurse’s station with the alarm sounding. When Resident #2 was observed and interviewed, she reported that she had activated the call light for toileting assistance. A CNA who was on her way to lunch entered the room approximately 45 minutes after the call light had been activated and found that the resident had already been incontinent in bed due to the delay. The CNA then assisted the resident into her wheelchair, to the bathroom, and with personal hygiene, and changed the urine-soiled bedding. Another agency CNA present at the nurse’s station acknowledged hearing the call system alarming but did not answer the call light. The LPN assigned to the resident also stated she heard the call light but assumed the aides would respond and was not aware which aide was assigned to that resident.
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