Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights, as evidenced by multiple resident interviews and review of call light response logs. Several residents, all with varying degrees of cognitive function and complex medical histories including heart failure, diabetes mellitus, hyperlipidemia, morbid obesity, arthritis, hip fracture, and mental health disorders, reported that call lights often took longer than 15 minutes to be answered, particularly during evenings, weekends, and morning shifts. These delays were corroborated by facility documentation showing response times ranging from 16 to 39 minutes on multiple occasions. The Director of Nursing acknowledged that call light response times were an ongoing issue and provided logs confirming extended delays. Additionally, the DON stated that the facility did not have a formal call light policy and instead relied on general standards of care. The expectation communicated by the DON was for call lights to be answered within 15 minutes, but this standard was not consistently met, as shown by both resident reports and facility records.