Failure to Timely Respond to Resident Call Lights Due to Inadequate Staffing
Penalty
Summary
Surveyors identified that the facility failed to provide adequate nursing staff to meet the needs of residents, specifically in timely response to call lights. Multiple observations and interviews revealed that residents who were dependent on staff for toileting and transfers experienced significant delays, with call lights remaining unanswered for extended periods, sometimes up to an hour and a half or more. Residents reported tracking the time it took for staff to respond, and noted that delays were less frequent during the survey period due to increased office staff involvement. Resident Council Meeting minutes from several months documented ongoing complaints about long waits for call lights, staff not returning as promised, and residents being left on the toilet for over 30 minutes, with no documented follow-up on these concerns. Staff interviews confirmed that staffing shortages contributed to the delays in answering call lights, with CNAs stating that they were sometimes unable to respond promptly due to insufficient staff, especially during call-ins. Observations included instances where management and nursing staff walked past rooms with active call lights without responding, and residents reported having to call the facility to get assistance. The Director of Nursing and Administrator acknowledged the expectation for call lights to be answered within 15 minutes, but this standard was not consistently met, as evidenced by the documented delays and resident reports.