F0550

D

Failure to Timely Respond to Call Light for Toileting, Affecting Resident Dignity

Mount Vernon, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to respond to a visually impaired resident’s call light in a timely manner to provide toileting assistance, as required to maintain dignity and self-determination. The resident was admitted with diagnoses including cerebral atherosclerosis and category 5 blindness in both eyes, and her care plan identified her as high risk for falls with interventions to anticipate and meet her needs, ensure her call light was within reach, and encourage its use for assistance. On one observed occasion, the resident’s call light was on and a CNA (V9) responded promptly. The resident’s family member stated the resident needed to use the restroom. V9 stated she was the only aide on the hall, that the resident required two staff for assistance at that time, then turned off the call light and left the room without toileting the resident.

Subsequent interviews and observations documented that the resident had last been toileted after breakfast and then laid down, and had not been toileted again until later that morning. Continuous observation of the room began, and when the call light came on again, another CNA (V10) answered and toileted the resident. Staff interviews indicated that the hallway was sometimes staffed with only two CNAs instead of the preferred three, despite having residents who required two-person assistance. Staff reported that when only two aides were present, they could request help from a nurse or a CNA from another hall. The DON stated that a 40-minute wait time for toileting due to needing a second staff member was not acceptable and that staffing should never prevent a resident from getting out of bed. The facility’s dignity policy states that care shall be provided in a manner that maintains or enhances each resident’s dignity and respect.