Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and observations. Several residents reported extended wait times for call light responses, with some waiting 15 to 60 minutes for assistance. One resident described being left on a bedpan for over an hour, resulting in numbness and discomfort, while another reported having to keep a partially filled urinal at the bedside due to delayed staff response. Residents consistently stated that staff told them the facility was short-staffed, and that call light response times varied depending on the day and staff present. Photographic evidence was obtained to support these claims. Staff interviews confirmed that call lights should be answered within 3 to 5 minutes, and the DON stated that the facility staffs based on census and acuity, never going below certain staffing thresholds. Despite this, residents continued to experience delays. The DON also indicated that all staff, including non-nursing departments, are expected to answer call lights, and that call light audits and ambassador rounds are conducted. However, when surveyors requested documentation of these audits, the administrator withheld the forms, stating the survey team was not permitted access.