F0725

E

Failure to Respond Timely to Call Lights and Tube Feeding Alarm

Waterloo, Iowa Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely responses to resident call lights and alarms, resulting in prolonged wait times for assistance. For one resident with moderately impaired cognition, myotonic muscular dystrophy, diabetes mellitus, and malnutrition, the care plan required assistance with ADLs and keeping the call light within reach due to fall risk. Despite this, call light log data showed multiple instances where this resident’s calls were not answered for extended periods, including waits of 46 minutes, 37 minutes, 27 minutes, 18–19 minutes, and one episode lasting 1 hour and 21 minutes. The resident reported that it took up to 2 hours for someone to answer her call light, and a CNA reported observing this resident’s call light on for over an hour during an overnight shift without staff notifying the nurse on duty.

Another resident, cognitively intact but dependent on staff for toileting hygiene, bed mobility, and transfers, with diagnoses including type 2 diabetes mellitus, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, also experienced prolonged call light response times. This resident’s care plan required assistance with ADLs and keeping the call light within reach due to fall risk. The grievance log documented that the resident reported staff refused to lay her down, turned off the call light, and left, after she had her call light on for over an hour. Call light logs showed multiple delays for this resident, including waits of approximately 33 minutes, 56 minutes, 32–33 minutes, 31 minutes, 20 minutes, 29 minutes, and one episode of 1 hour and 47 minutes before the call was answered.

A third cognitively intact resident with diabetes, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, who was at risk for falls and had occasional bladder incontinence, also reported unaddressed call lights. This resident’s care plan required that the call light be kept within reach. The grievance log recorded that from 1:00 AM to 3:00 AM the resident had her call light on and no one answered, and that she had to ask her roommate to press the call light because her own was not within reach. Call light logs for this resident showed waits of 51 minutes and 36 minutes. In addition, a resident with paraplegia, seizure disorder, CAD, respiratory failure, malnutrition, and dependence on a feeding tube for more than half of daily calories and fluids had a tube feeding pump alarm sounding continuously for nearly an hour. Multiple staff, including housekeeping, another staff member, the DON, and an LPN, passed by or were present in the hallway without responding to the audible alarm until the surveyor alerted the LPN, who then identified an occlusion-related cassette error on the pump. The facility did not have a written policy to ensure timely call light response, and the DON acknowledged that residents had complained about call light wait times and that some documented waits were too long.