Failure to Provide Sufficient Staff for Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly in the areas of toileting assistance and timely response to call lights. Multiple observations documented residents waiting extended periods for assistance, including one resident with a history of hip fracture and impaired mobility who was left sitting on the toilet for half an hour with her catheter bag improperly positioned, and another resident who waited in a soiled brief for staff to assist with changing. Call lights were observed to be activated for prolonged periods without response, and residents and their roommates reported repeatedly calling for help without timely staff intervention. Interviews with residents revealed consistent concerns about delayed responses to call lights, with some reporting waits of up to two hours for assistance with transfers and personal care. Residents described staff placing multiple briefs on them to reduce the frequency of changes, which caused discomfort. Staff interviews confirmed that staffing levels were inadequate, with frequent reliance on agency staff and management personnel filling in for direct care roles. Staff reported being called to work extra hours and noted that most residents required assistance from two staff members, especially for transfers involving mechanical lifts. Review of facility records, including call light response reports, resident council meeting notes, and the facility assessment, corroborated the observations and interviews. Call light response times frequently exceeded the facility's 15-minute expectation, with some instances documented at over an hour. Resident council notes and grievance logs indicated ongoing concerns about call light response times, with multiple residents expressing dissatisfaction over several months. The facility assessment acknowledged the high acuity and dependency of the resident population, but staffing plans and actual staffing levels did not consistently ensure timely care and response to resident needs.