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, staff interviews, and direct observations. Several residents reported untimely responses to call lights, with one resident stating she often received incontinence care only once during the first shift and had to wait extended periods for assistance. Another resident described being left in a hallway for two hours after requesting help to return to bed, and others confirmed that staff frequently cited being short-handed as the reason for delays. Staff interviews corroborated these accounts, with CNAs and LPNs reporting high resident-to-staff ratios, feelings of being overwhelmed, and an inability to provide timely care due to insufficient staffing, especially during certain shifts such as 3-11 p.m. Observations by surveyors further supported these concerns. On multiple occasions, call lights were observed to be active for extended periods while staff were present in the area but did not respond promptly. In one instance, a bathroom alarm was sounding while a unit manager sat at the nurse's station and a CNA walked past the room without responding, indicating a lack of immediate action to resident needs. The resident council president and other residents also reported that staff often disappeared from the floor during evening shifts and that there were fewer CNAs than expected, leading to longer wait times for assistance. A review of facility records revealed unresolved grievances related to call light response times, with at least one resident stating her complaint had not been addressed or followed up on. The staffing coordinator confirmed that CNA assignments could reach up to 12 residents per CNA, and nurses could have up to 40 residents, though typically had 25-31. The facility did not have a formal staffing policy, and while call light audits and room rounds were being conducted, there was no established expectation for response times. The combination of high resident-to-staff ratios, lack of prompt response to call lights, and unresolved grievances demonstrates the facility's failure to ensure sufficient staffing to meet resident needs.