Failure to Provide Sufficient Nursing Staff and Timely Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of all residents, as evidenced by multiple sources including policy review, job descriptions, resident council minutes, grievances, and interviews with residents, families, and staff. Residents and their families reported excessive delays in call bell responses, with some call bells going unanswered for up to an hour or more, particularly on weekends. Residents described situations where staff would respond to call bells only to state they were not the assigned aide and would not assist, or would promise to return but failed to do so. These concerns were consistently documented in resident council meetings and grievance logs over several months, with repeated reports of long wait times for assistance, including while on the toilet or waiting to be put to bed. Facility policies and job descriptions require prompt response to call lights and assistance to residents regardless of staff assignment, but these procedures were not followed. Eight alert and oriented residents interviewed confirmed ongoing issues with delayed responses and lack of assistance, corroborated by family observations and documented grievances. During interviews, facility leadership acknowledged awareness of these concerns as reflected in council minutes and grievance logs, but did not provide additional information to address the staffing-related issues.