Insufficient Staffing Leads to Delayed Call Light Responses and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times and unmet care needs for multiple residents. Resident council minutes and confidential group interviews revealed ongoing concerns about delayed responses, particularly at night and during early mornings, with residents reporting wait times ranging from 5 to 45 minutes or more. Residents described episodes of incontinence, frustration, and instances where staff were unable to assist due to being occupied with other duties, such as feeding other residents. Several residents reported having to wait for assistance with toileting, meals, and other essential needs, with some resorting to calling out to non-clinical staff for help or attempting to manage their needs independently despite risks. Specific cases included a resident with left-sided hemiplegia following a stroke who required moderate to maximum assistance for transfers and toileting. This resident reported an incident where her call light went unanswered for approximately two hours, leading her to call 911 for help. Documentation confirmed the event, and the resident was subsequently provided with alternative means to contact staff. Another resident with a history of falls and a recent elbow fracture reported waiting over 20 minutes for call light responses and often attempted to use the bathroom independently due to urgency, despite being at high risk for falls and requiring assistance per her care plan. Facility call light logs corroborated multiple instances of response times exceeding 25 minutes for this resident. A third resident, dependent on staff for toileting and always incontinent, reported waiting at least 45 minutes for assistance, resulting in prolonged exposure to soiled conditions. This resident also expressed concern about choking risks due to delayed help with meals. Facility records showed numerous call light response times exceeding 25 minutes for this resident, with some waits approaching or exceeding an hour. Staff interviews confirmed ongoing staffing shortages, particularly on weekends, and described situations where aides on light duty were required to assist with resident care due to insufficient staffing levels.