Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two residents who required assistance with activities of daily living, specifically toileting. One resident, who was cognitively intact and required substantial to maximal assistance for toileting due to multiple medical conditions including respiratory failure, heart failure, and morbid obesity, reported waiting up to 45 minutes for assistance after activating the call light in the early morning hours. This resident stated that delays were most pronounced during evening and overnight shifts and that he was frequently left on the toilet for extended periods. Staff interviews confirmed that call lights were not always answered promptly, particularly during shift changes or when staffing levels were low, with one CNA noting that the average response time could be fifteen minutes or longer depending on circumstances. Another resident, also cognitively intact and requiring supervision or assistance for toilet hygiene, reported rarely using the call light and instead seeking staff directly for help. However, when the call light was used, the resident stated it was generally answered in a timely manner. Despite this, the facility's ombudsman and multiple CNAs corroborated ongoing concerns about delayed call light responses, especially during times of reduced staffing. Resident Council meeting minutes further documented repeated complaints about untimely call light responses over several months. Staff interviews consistently indicated that insufficient staffing contributed to delays in responding to residents' needs, particularly for toileting and other personal care tasks. Several CNAs and nurses acknowledged that they were unable to meet residents' needs promptly, especially when only one CNA was available per unit or during busy periods. The facility's policy required immediate response to call lights, but this standard was not consistently met, as evidenced by both resident and staff reports as well as facility documentation.