Failure to Provide Timely Staff Assistance for Residents with High Care Needs
Penalty
Summary
The facility failed to provide timely staff assistance for two residents with severe cognitive impairment and significant care needs. One resident, diagnosed with Parkinson's disease, non-Alzheimer's dementia, and anxiety, was identified as dependent on staff for toileting and transfers. Despite a care plan directing staff to assist with toileting at specific times and as needed, the resident's family reported that a CNA walked by the room while the call light was on and did not respond for 35 minutes, requiring the family to seek out staff assistance. Another resident, with diagnoses of heart failure and diabetes mellitus and also severely cognitively impaired, called out for help to use the bathroom. Although staff were present in the area, they informed the resident they were busy and would assist shortly, but the resident waited 21 minutes before receiving help. Staff interviews confirmed that call light response times could reach up to 15 minutes or more, and the DON stated the expectation was a maximum of 15 minutes for response. Review of staff training records revealed that one CNA had not completed the required competency training on call light response times.