Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and preferences of residents, as evidenced by prolonged call light response times and unmet care needs for multiple residents. Observations revealed that call lights remained unanswered for extended periods, with one resident waiting 25 minutes and another 20 minutes. Residents were observed calling out for assistance, and staff were not present in the hallways during these times. One resident, who had recently returned from the hospital after an amputation, was left waiting for pain medication, reporting severe pain and a significant delay since his last dose. His care plan required timely pain management, but the delay in response resulted in unmanaged pain. Another resident, dependent on staff for transfers, reported waiting approximately 30 minutes for assistance to return to bed and described routine delays due to staffing shortages. She expressed frustration with the long wait times and noted that CNAs were overworked, handling multiple responsibilities simultaneously. A third resident, with a history of respiratory issues and anxiety, also experienced delays in receiving her inhaler before scheduled therapy, leading to increased anxiety and physical symptoms. She noted that long wait times for call light responses were consistent regardless of shift or day. Staff interviews confirmed that call lights were often left unanswered due to heavy workloads and insufficient staffing, particularly during night shifts and meal service times. CNAs reported being assigned to multiple residents with high care needs, making it difficult to respond promptly to all requests. Resident Council meeting minutes and interviews with the Resident Council President highlighted ongoing concerns about staffing shortages, which had been repeatedly discussed without resolution. Facility policies required prompt call light response, and the facility assessment acknowledged the need for staffing adjustments based on resident acuity and care needs, but these standards were not met in practice.