Failure to Respond Promptly to Resident Call Light
Penalty
Summary
The facility failed to respond to a resident’s call light in a timely manner, despite policies and job descriptions requiring prompt response. On multiple observations, the call light system monitor at the 2nd floor nursing station showed that the resident’s room call light had been activated for extended periods, with the hallway light outside the room remaining on. On one day, the call light for this resident’s room remained active from at least 12:53 PM until 1:11 PM, and the resident reported that it took staff a long time to check on him. On another day, the monitor showed the resident’s call light had been on for 62 minutes while an LPN sat at the nursing station; the LPN acknowledged that the system tracks minutes since activation and stated that someone likely went in but forgot to turn off the light, although the hallway light remained on. The resident involved had diagnoses including paraplegia, colostomy care, joint contractures, intestinal obstruction, UTI, and urogenital implants, and his MDS indicated intact cognition with substantial/moderate assistance needed for toileting, bathing, lower body dressing, personal hygiene, and transfers. His care plan identified him as at risk for falls related to generalized weakness and paraplegia, with interventions including keeping the call light within reach and encouraging its use for assistance. The resident reported that a CNA brought him a bucket of water at about 10:50 AM so he could bathe himself, but he could not wash his feet independently and activated his call light for help; more than an hour later, no staff had entered his room, and the CNA confirmed she had not returned since 10:50 AM and had been busy passing meal trays. Both the CNA and LPN stated that call lights should be answered right away or as soon as possible, and the DON stated that call lights should be responded to within 15 minutes, noting that staff do not know why a resident triggered the call light unless they check on them. Facility policy and the CNA job description both require call lights to be answered promptly.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.