Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs for multiple residents. One resident, who was cognitively intact and had chronic obstructive pulmonary disease and diabetes, reported call light response times ranging from 35 minutes to one hour and 45 minutes, with delays occurring on any shift. Another resident with hemiplegia and hemiparesis following a stroke reported having to remain in soiled briefs for hours, particularly during the day shift, and noted that more than one staff member was needed to assist with changing. A third resident, also cognitively intact and requiring assistance with personal care, reported waiting up to an hour for call light responses and that staff would sometimes acknowledge the call but not return to provide assistance, especially when the resident wanted to get out of bed in the morning. Staff interviews confirmed that the facility experienced short staffing, particularly on weekends and at least three times in the prior three months. The scheduler indicated that staffing was based on census and acuity, and that some residents required more staff time, which contributed to delays. During a Resident Council meeting, all residents present reported insufficient staffing, with specific concerns about long wait times for call light responses, especially at night and after 6pm. Residents also reported that staff sometimes turned off call lights without addressing their needs.
Plan Of Correction
F725 – Sufficient Nursing Staff Element #1 Residents #2, #25, and #37 were individually assessed to ensure their current needs were being met without delay. Their care plans were reviewed and updated as needed to include prompt response protocols and individualized care interventions. Element #2 A facility-wide audit will be completed by the Director of Nursing and/or designee to evaluate call light response times and overall resident satisfaction with care timeliness. Resident Council concerns were formally reviewed during the June meeting and integrated into the action plan. Element #3 The Administrator reviewed the policy on Call Light Accessibility and Timely Response, and revised as necessary. Community staff were provided education on the policy to include timely response standards and the importance of resident-centered care. Element #4 The Director of Nursing and/or designee will conduct random call light response audits for 10 residents weekly for 12 weeks. In addition, 5 resident interviews regarding call light responsiveness and care timeliness will be completed weekly by Social Services. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025