Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by prolonged call light response times and lack of staff presence in resident areas. Observations included a 45-minute period with no staff present on the 200 hall and a 45-minute call light wait time. Residents reported ongoing issues with long call light wait times, particularly during shift changes, and expressed frustration and anger over delays in receiving assistance. Resident council minutes also documented repeated concerns about untimely responses to call lights. Specific examples included a resident with a BIMS score of 15, indicating cognitive intactness, who observed staff frequently neglecting call lights in favor of personal activities such as using phones and taking cigarette breaks. Another resident, also cognitively intact and requiring assistance with personal care, reported waiting 30 minutes for help while experiencing discomfort, with no staff present in the hallway. Staff interviews confirmed that CNAs were often responsible for multiple pods, making it difficult to respond promptly to call lights, and that long wait times were a common issue.