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 six out of eight residents reviewed for call light response. Multiple residents with significant medical needs, including diabetes, obesity, major depressive disorder, post-traumatic stress disorder, hemiplegia, and incontinence, reported delays in receiving assistance after activating their call lights. These residents were dependent on staff for activities of daily living such as toileting, bathing, and incontinence care, and several reported waiting up to an hour for help or experiencing incontinence episodes while waiting for staff to respond. Interviews with residents revealed consistent concerns about insufficient staffing levels, particularly during certain shifts or on weekends. Residents described situations where only two CNAs were available for the entire facility, leading to delays in care, missed showers, and unmet toileting needs. Some residents were unable to recall the exact wait times but indicated that the delays were significant enough to result in discomfort or incontinence. Staff interviews corroborated the residents' accounts, with CNAs and an LPN acknowledging that staffing shortages made it difficult to answer call lights and provide timely care. Staff described working shifts with only one or two CNAs, sometimes being left alone for extended periods, and being unable to complete scheduled showers or incontinence care. The administrator confirmed that the facility often operated with fewer CNAs than ideal, and that nurses were expected to assist on the floor when possible.