Failure to Provide Sufficient Nursing Staff Resulting in Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with cognitive impairment, mobility limitations, and incontinence, experienced significant delays in receiving assistance. For example, one resident with memory loss reported waiting approximately 30 minutes for staff to answer the call light on multiple occasions, as confirmed by call light logs and staff interviews. Staff acknowledged that busy times, such as mornings and mealtimes, contributed to delays, with some staff reporting that they could only assist one resident at a time while multiple call lights were active. Another resident with a femur fracture and requiring assistance with activities of daily living waited up to an hour for help with toileting, as documented in a grievance form and corroborated by staff. The resident reported being left on a bedpan for 20 to 30 minutes until the shift changed, and staff confirmed the resident's complaint. Additional residents with conditions such as respiratory failure, kidney disease, and recent fractures also experienced call light response times ranging from 25 minutes to over an hour, leading to episodes of incontinence and discomfort. Call light logs and resident statements consistently indicated that response times exceeded the facility's stated expectation of five to fifteen minutes. Staff interviews, including those with CNAs and the Director of Nursing Services, confirmed awareness of the delays and the expectation for timely responses. However, documentation and direct observation revealed that these expectations were not met, particularly during busy periods. The lack of adequate staffing and delayed responses placed residents at risk for unmet needs and compromised their ability to attain or maintain their highest practicable well-being.