Failure to Maintain Resident Dignity Through Timely Call Bell Response
Penalty
Summary
The facility failed to maintain resident dignity by not responding promptly to call bells for two residents who were cognitively intact and dependent on staff for assistance with toileting, hygiene, and transfers. For one resident with multiple sclerosis, a quarterly MDS dated January 9, 2025, showed he was alert, oriented, and able to make his needs known, but required staff assistance for daily care. Interview with this resident on February 28, 2023, revealed he had to wait an extended period for staff to respond to his call bell. Review of his call bell logs for January and February 2026 showed multiple instances of prolonged response times, including waits of 19, 21, 27, 19, 60, 41, and 18 minutes on various January dates, and 16 and 46 minutes on February 1, 2026. These delays occurred despite a facility policy dated October 28, 2025, stating that staff alerted to an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. Another resident, with an annual MDS dated January 6, 2026, was cognitively intact and required staff assistance for daily care needs due to hemiplegia and hemiparesis following a stroke, as well as diabetes. A grievance form dated December 15, 2025, documented that this resident reported being put to bed around 10:00 p.m. and not being checked on until about 4:00 a.m., during which time he attempted to call the nurses’ station with his cellphone but received no answer until staff eventually came and told him they were short staffed. Review of his call bell log from December 14–16, 2025, showed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time was one hour and 47 seconds. In a February 3, 2026, interview, the resident stated that it took staff a long time to get him into bed after his request and that he sometimes called the front desk to get a faster response, but that night no one answered the phone. The Assistant DON acknowledged in a February 3, 2026, interview that the documented call bell wait times were excessive and not acceptable, and stated that she expects call bells to be answered within five minutes, noting that anyone can answer a call bell.
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