F0550

E

Failure to Answer Call Lights Timely, Affecting Multiple Dependent Residents

Humble, Texas Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to treat residents with respect and dignity by not answering call lights in a timely manner, despite care plan directives and facility policy. One resident, an older female with COPD, hypothyroidism, hyperlipidemia, schizophrenia, hypertension, type 2 diabetes with hyperglycemia, and paraplegia, was totally dependent on staff for all ADLs. Her care plan required that the call light be kept within reach at all times due to risks related to seizures and falls. She reported that it took staff at least 30 minutes or more to answer call lights on multiple occasions when she needed to be changed, leaving her sitting in a soiled brief. She stated that this created a feeling of helplessness, worsened her depression, and that the call light issue was ongoing and had been raised in resident council as a grievance.

Another resident, an older female on hospice with COPD exacerbation, immunodeficiency, type 2 diabetes with polyneuropathy, upper respiratory infection, anxiety disorder, and hypertensive heart disease with heart failure, had a baseline MDS showing moderate cognitive impairment and required supervision or touching assistance for all ADLs. Her care plan required that the call light be kept within reach at all times and that she receive diabetic snacks between meals and at bedtime. She reported that when she pushed her call light for her evening snack, it took approximately 45 minutes or more to be answered, and sometimes it was not answered at all, resulting in her not receiving the snack and feeling nauseated and sick to her stomach. A third resident, an older female with multiple diabetes-related diagnoses, diverticulitis, moderate cognitive impairment, and extensive ADL assistance needs, had care plan approaches including keeping the call light in reach at all times due to fall risk and monitoring for dehydration and pressure injury.

During an observation, this third resident activated her call light while sitting on the side of her bed. Twenty minutes later, an RN entered the room, walked past her, looked behind the curtain of the absent roommate, and then left the room without addressing the activated call light. In a subsequent interview, the resident stated she very seldom used the call light but recalled being extremely sick on one occasion when it took more than 30 minutes for staff to respond, and she expressed fear that if she were dying she might be dead before staff responded. Additional residents reported that call lights routinely took 30 minutes to 1.5 hours to be answered, and the resident council secretary confirmed that long wait times for call lights were an ongoing issue documented in council minutes. The Ombudsman reported multiple complaints about unacceptable call light response times, particularly on night shift. Staff interviews showed awareness that answering call lights after 30 minutes was not acceptable and that all staff could and should answer call lights, while the ADON characterized the issue as a perception problem. The RN observed failing to respond to the call light acknowledged he did not address the resident’s needs despite the light being on and stated this could have resulted in the resident being in distress. The facility’s call light policy required staff to respond to call lights and requests for assistance as quickly as practicable and to respond to emergency lights immediately, which was not followed in these instances.