Failure to Provide Timely Response to Call Lights Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights for all residents reviewed, as evidenced by multiple resident interviews, observations, and record reviews. Several residents, all with significant care needs such as morbid obesity, heart failure, stroke, hemiplegia, and cognitive impairments, reported excessive delays in staff responding to their call lights, with some waiting over an hour and, in one case, over two hours. Residents consistently described situations where staff would turn off call lights, promise to return, and then not come back for extended periods, leaving residents without necessary assistance for toileting, transfers, and other essential care needs. Observations confirmed that call lights were not always accessible to residents, with instances where the call light was out of reach, preventing residents from requesting help. One resident was observed with the call light cord draped over the bed footboard and the button out of reach, and another resident confirmed they could not access the call light when needed. The facility's policy required call lights to be within reach and secured as needed, but this was not consistently followed. The Director of Nursing acknowledged that the policy did not specify a required response time but stated her expectation was for call lights to be answered within 15 minutes. Residents reported negative experiences due to these delays, including being left wet for extended periods, which contributed to ongoing skin issues, and having to leave their rooms to seek assistance themselves. The facility census at the time was 79 residents, and the deficiency was identified through a combination of resident interviews, staff interviews, observations, and policy review.