Failure to Provide Sufficient Nursing Staff Resulting in Excessive Call Light Wait Times
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available each day to meet the needs of residents, as evidenced by repeated excessively long call light wait times for multiple residents. Review of call light activation logs for seven sampled residents revealed numerous instances where residents waited between 30 minutes to over an hour and a half for staff response. These delays occurred across various times of day and affected residents with significant care needs, including those with cerebral palsy, recent fractures, quadriplegia, stroke, muscle weakness, and incontinence. Care plans for these residents required timely assistance for activities of daily living, fall prevention, and incontinence care, but the documented wait times indicate these needs were not consistently met. Interviews with residents confirmed the pattern of delayed responses, with several residents stating they often waited over an hour for assistance, particularly for toileting and repositioning. Some residents reported having to self-transfer or remain soiled for extended periods due to the lack of timely staff response. The Resident Council also reported frequent and prolonged call light wait times, sometimes up to an hour and a half, and noted that staff would sometimes place call lights out of residents' reach. Staff interviews corroborated these concerns, with nursing staff acknowledging that excessively long wait times were not safe and could lead to negative outcomes such as falls or unmet care needs. Observations by surveyors further substantiated the deficiency, including the presence of strong urine odors in resident areas and direct observation of a resident left in soiled incontinence products for an extended period. Facility leadership acknowledged that staffing was determined based on state minimums and acuity, but also recognized that the current resident population required more staff due to increased care needs. Despite daily reviews of staffing levels, the facility did not consistently provide enough staff to ensure timely care and response to resident needs, as required by regulation.