F0558

E

Failure to Ensure Timely and Accessible Call Light Response for Multiple Residents

Bridgeville, Pennsylvania Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure call lights were accessible and answered promptly, as required by facility policy and state regulations, for six of seventeen residents. The facility’s call light policy dated 7/15/25 states that each patient will have a call light or alternative communication device at the bedside, toilet, and bathing room, and that staff will respond promptly. Despite this, multiple residents with intact cognition (BIMS scores ranging from 13 to 15) reported delays in staff response to call lights, particularly on evening and night shifts, and facility leadership confirmed that call lights were not answered in a timely manner.

One resident with chronic respiratory failure, retropharyngeal and parapharyngeal abscess, and fibromyalgia, who required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers, reported in a written statement that a nursing assistant criticized her for using the call light too much and made her wait to go to the bathroom. Another resident with spastic quadriplegic cerebral palsy, diabetes mellitus, and anxiety disorder, who was dependent for toileting hygiene and unable to perform toilet transfers due to medical condition, stated during interview that when she used the call light it often took thirty minutes or more to receive help, and that she could not care for herself and simply had to wait.

Additional residents also described frequent delays in call light response. A resident with multiple sclerosis, a stage IV pressure ulcer, and malnutrition, who was independent with toileting hygiene but required partial/moderate assistance with toilet transfers, reported that it took thirty to forty-five minutes to get help, especially on evening and night shifts, occurring a couple of times each week. Another resident with COPD, diabetes mellitus, and depression, independent in toileting hygiene and toilet transfers, stated that when using the call light for needs such as medication or feeling unwell, waiting times on evenings and nights were about thirty minutes or longer. A long-stay resident with hypertension, heart failure, and depression, dependent for toileting hygiene and unable to perform toilet transfers, filed grievances on two consecutive days about daily call light wait times on evening and night shifts, later reporting that although things had improved, she still waited thirty minutes to two hours several times a week. A further resident with hypertension, diabetes mellitus, and cellulitis, requiring substantial/maximal assistance for toileting hygiene and toilet transfers, reported in a written statement that he repeatedly tried to call because he had soiled himself and no one came, leading him to call his family, who then came to the facility and reported he was not being changed. The Nursing Home Director and DON confirmed that the facility failed to ensure call lights were accessible and answered timely.