Deficiency in Sufficient Nursing Staff and Timely Call Bell Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely response to call bells for at least one resident, as evidenced by multiple call bell response times exceeding 15 minutes. Audit reports for a specific resident showed several instances where response times ranged from 15 minutes and 25 seconds to 17 minutes and 39 seconds. Interviews with staff indicated that call bells should be answered within five minutes or as soon as they are noticed, while an interviewed resident and representative expected responses within 15 minutes or less. The facility's own policy stated that call lights should be answered immediately to ensure timely responses to residents' needs. A review of the resident's electronic medical records and Minimum Data Set (MDS) indicated that the resident had certain diagnoses and a Brief Interview for Mental Status (BIMS) score, but the specific details were redacted. The resident was assessed as needing timely assistance, and the expectation for prompt call bell response was confirmed by both staff and the resident's representative. Despite these expectations and the facility's policy, the documented response times exceeded the expected timeframe on multiple occasions. Additionally, the facility was found to be out of compliance with New Jersey's minimum staffing requirements for three out of fourteen day shifts during a two-week period, having only 11 CNAs for 93 residents when at least 12 were required. This staffing shortfall contributed to the delayed response times and the facility's failure to meet both state and federal regulations regarding sufficient nursing staff and timely care.
Plan Of Correction
Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2) 483.35(a) Sufficient Staff. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 182 NJ Ex Order 26.4(b)(1) in the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Nursing Home Administrator or designee conducted in-servicing on call lights were answered timely. The Nursing Home Administrator or designee will conduct audits on timely call light response, toileting timely, receiving medications timely, receiving meals timely, and timely assistance with dressing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Nursing Home Administrator or Director of Nursing will conduct audits on 10 residents for timely call light response, weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. Facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Nursing Home Administrator or designee conducted in-servicing on call lights were answered timely. The Nursing Home Administrator or designee will conduct audits on timely call light response, toileting timely, receiving medications timely, receiving meals timely, and timely assistance with dressing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Nursing Home Administrator or Director of Nursing will conduct audits on 10 residents for timely call light response, weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 725