Untimely Call Light Response for Residents Requiring Extensive Assistance
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for three cognitively intact residents who required extensive assistance with ADLs and mobility. One resident, who was dependent for sit-to-stand and bed-to-chair transfers and required extensive assistance with dressing, toileting, and transfers using a Hoyer lift, reported using the call light to have his urinal emptied and to get in and out of bed. He stated that call lights could take from 30 minutes to an hour and a half to be answered and that he preferred to get up at 6 a.m. but was sometimes not assisted out of bed until 8 a.m., which made him feel terrible and shaky because he wanted to get up. Another resident, with a BIMS score indicating intact cognition, reported using the call light to request breathing treatments and stated he typically waited 20–30 minutes for staff to respond. If no one responded within that time, he would go to the nurse’s station himself, where he observed nurses and CNAs sitting at the station, and he stated that the wait time made him feel angry. A third resident, also cognitively intact and requiring substantial/maximal assistance for toileting hygiene and transfers with a mechanical lift, reported using the call light to request ice and incontinence care. This resident stated that the worst wait time for a call light response was up to an hour, which made him feel frustrated. His care plan included interventions such as two-person extensive assistance for toileting, two-person total assistance with a mechanical lift for transfers, and offering toileting on rounds, upon request, and as needed. CNAs interviewed on the night shift reported feeling rushed and hurried, with one CNA assigned 15–17 residents and another 18–23 residents when the facility was short staffed, and one CNA stated she did not take her ten-minute breaks. The facility’s Resident Rights policy required employees to treat residents with kindness, respect, and dignity and to assist each resident in exercising their rights, but residents’ reports of prolonged call light response times and associated negative feelings demonstrated that this was not consistently achieved.
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