Failure to Provide Sufficient Staffing Results in Prolonged Call Light Response Times and Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with significant physical and psychosocial needs, experienced extended waits for assistance, sometimes exceeding one to three hours. These delays were documented through call light logs and corroborated by resident interviews, which described repeated instances of unmet needs for toileting, hygiene, and mobility assistance. Staff interviews confirmed that inadequate staffing levels, particularly when only two nursing assistants were present instead of the expected three, contributed to the inability to respond to call lights in a timely manner. One resident with multiple sclerosis, anxiety, depression, and a history of trauma was left waiting for nearly three hours for incontinence care, leading to increased anxiety, distress, and feelings of helplessness. This resident was dependent on staff for transfers and personal care, and her care plans emphasized the importance of timely assistance to prevent urinary tract infections and support her psychosocial well-being. Despite these documented needs, call light logs showed frequent delays, and the resident reported feeling unsafe and emotionally affected by the lack of prompt care. Other residents with conditions such as Parkinson's disease, functional quadriplegia, and pressure ulcers also experienced similar delays, sometimes resulting in incontinence episodes and emotional distress. Staff interviews revealed that the shortage of nursing assistants made it difficult to answer call lights promptly, especially during times when staff were pulled to cover other duties or when scheduled staff left due to illness. Residents and their representatives described feelings of helplessness, frustration, and loss of dignity due to the prolonged waits. The facility's own grievance logs and staff acknowledged the negative impact of these delays on residents' psychosocial well-being, including increased anxiety and diminished trust in staff. The documented call light response times and resident accounts demonstrate a pattern of insufficient staffing leading to unmet resident needs.