Insufficient Nursing Staff Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the needs of all residents, resulting in prolonged call light response times and delays in assistance with activities of daily living, including toileting and personal care. Multiple residents reported that on weekends, staffing was particularly inadequate, with only one nurse and one CNA assigned to their unit. One resident described waiting five hours for a diaper change, timing the delay from 4:00 PM to 9:00 PM, and noted that no staff communicated the reason for the delay. Another resident reported waiting forty to sixty minutes for staff to respond to call lights on several occasions, especially during the evening shift, and expressed concern about the lack of communication from staff regarding delays. Family members also reported difficulty reaching staff to request assistance for residents, with one family member making multiple unsuccessful attempts to contact the nurse's station about a soiled diaper. Residents and family members described hallways being empty and staff unavailable, particularly on weekends. One resident stated she had to walk to the bathroom unassisted due to unanswered call lights. Staff interviews confirmed that complaints about delayed call light responses were common, especially on weekends, and that agency staff required additional supervision. The DON acknowledged receiving complaints about prolonged response times, mainly from family members over the weekend. During a resident council meeting, all present residents unanimously expressed concerns about long wait times for staff to respond to call lights, with reported delays ranging from 30 minutes to over three hours, again noting weekends as the worst. The facility's own policy requires prompt response to resident calls for assistance, but the evidence gathered from resident, family, and staff interviews, as well as direct observations, demonstrates a consistent failure to meet this standard.