Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
Surveyors observed multiple instances where residents' call lights were left unanswered for extended periods, and residents requiring assistance did not receive timely care. On one occasion, two residents' call lights remained activated for over 15 minutes while a CNA attended to another resident, passing by the rooms without responding. Additional residents activated their call lights during this period, and staff were not present in the hallway. When the CNA eventually responded, residents requested assistance with toileting and repositioning, indicating unmet needs during the delay. Facility policy requires all staff to respond promptly to call lights, but this was not followed. A resident with Alzheimer's and Parkinson's disease, who required a mechanical lift and two staff for transfers, was left sitting alone in a shower chair for over 40 minutes due to insufficient staff available to assist with her transfer. Staff interviews confirmed that only two aides were present instead of the usual three, resulting in delays. The resident was eventually transferred to bed, and staff noted red indentations on her leg from prolonged sitting. Staff and the DON acknowledged that residents should not be left in shower chairs and that adequate staffing is necessary to meet residents' needs. Additional interviews with residents and staff revealed frequent delays in call light response, with some residents reporting waits of 30 minutes to over an hour, particularly during shifts with reduced staffing. Residents with significant mobility and cognitive impairments, as well as those dependent on staff for activities of daily living, were affected by these delays. Staff and the DON confirmed that call lights should be answered within 15 minutes, but this standard was not consistently met due to staffing shortages.