Failure to Address Resident Council Concerns on Staffing and Call Light Response
Penalty
Summary
The facility failed to adequately address ongoing concerns raised by the Resident Council regarding staffing levels and call light response times over a nine-month period. Resident Council minutes repeatedly documented complaints about insufficient staff on weekends, delayed responses to call lights, and staff not assisting residents with getting up or providing care during certain shifts. Despite these recurring concerns, the facility's responses were limited to general statements, requests for more specific information, or references to individual cases, without evidence of comprehensive investigation or resolution. Documentation such as call bell audits and records of supervisory rounds or spot checks, which were cited as part of the facility's response, were not provided for review. Observations during the survey confirmed that call lights were left unanswered for extended periods, and staff sometimes turned off call lights before residents' needs were met. For example, one resident's call light remained on and flashing for a prolonged time, and the resident reported that their need was not met even after the call light was answered. Another resident waited over an hour for acetaminophen after activating their call light. Staff interviews corroborated that call lights were not always answered promptly, often due to multiple simultaneous calls and insufficient staffing. Interviews with facility leadership revealed a lack of clear policies or targets for call light response times, and there was no evidence that the concerns raised by the Resident Council were systematically addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process. The Regional Director of Operations and Regional Nurse Consultant were unable to provide documentation of corrective actions or performance improvement plans related to these issues. The facility's grievance policy required prompt investigation and resolution of complaints, but there was no documentation that this process was followed for the Resident Council's ongoing concerns.