Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet toileting needs for multiple residents. Observations and interviews revealed that residents experienced significant wait times, sometimes exceeding 15 minutes, for assistance with toileting and transfers. One resident, who required partial assistance for transfers and toileting, reported waiting longer than 15 minutes for help, leading to episodes of incontinence and emotional distress. Another resident, dependent on staff for all transfers and toilet hygiene, described waiting over 1.5 hours to be changed, resulting in attending activities in soiled clothing and feeling upset about personal hygiene. Continuous observations documented instances where call lights remained on for extended periods, such as a 22-minute wait, with staff and even the administrator walking past without responding. In one case, a resident had to call out for help and ultimately relied on a family member for assistance after staff failed to respond, resulting in an incontinence episode. Staff interviews confirmed that short staffing, particularly on the afternoon and evening shifts, made it difficult to answer call lights promptly, especially for residents requiring more intensive assistance. The facility's own policies emphasized the importance of timely responses to call lights and maintaining resident dignity by avoiding demeaning practices such as delayed toileting assistance. Despite these policies, both nursing and administrative staff acknowledged that call lights were often not answered within the expected timeframe, and that staffing shortages contributed to these delays. The Director of Nursing, Assistant Director of Nursing, and Administrator all recognized that residents were left waiting for assistance, sometimes resulting in incontinence and residents turning off call lights themselves after prolonged waits.