Insufficient Staffing Leads to Delayed Call Light Response and Improper Lift Use
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and improper use of mechanical lifts. Multiple staff and residents reported that the facility was frequently understaffed, with staff often required to pick up extra shifts or work with travel agency personnel to cover absences. Residents reported waiting between 20 to 40 minutes for call lights to be answered, and facility documentation confirmed several instances where call lights were not answered within the facility's expected 15-minute timeframe. The facility did not have a written policy on call light response available for review during the survey. Additionally, staff reported using mechanical lifts for resident transfers without the required two-person assistance, as specified in resident care plans. Staff admitted to performing single-person transfers with mechanical lifts when unable to find assistance, despite knowing this was against expected practice. The facility was unable to provide a written policy on lift use, and staff relied on personal judgment or video demonstrations rather than formal guidance. One resident confirmed that sometimes only one staff member assisted with transfers, contrary to their care plan requirements.