Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by delayed responses to call lights and unmet basic care needs for one resident. The resident, who was cognitively intact and required substantial to maximal assistance for toileting and was dependent for toilet transfers, reported waiting 40 minutes for assistance after activating the call light due to a full urinal. Unable to wait any longer, the resident urinated on himself and his bedding, resulting in emotional distress and feelings of worthlessness. The resident stated that call light wait times on evening and night shifts ranged from 20 minutes to two hours, and that staff did not respond promptly to requests for help. Interviews with CNAs confirmed that staffing levels were insufficient, with one CNA assigned to as many as 24 residents on some shifts and reporting that call lights were often answered late due to workload. Another CNA reported being assigned 12 to 20 residents and described short staffing as a common occurrence, making it difficult to meet residents' needs and requiring staff to skip breaks. The facility's policy requires sufficient nursing staff to provide care in accordance with resident care plans, but observations and staff interviews indicated that this standard was not met.