Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of all residents, specifically resulting in delayed toileting and incontinence care for a resident with significant medical needs. The resident, who had diagnoses including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, required total staff assistance for toileting, hygiene, dressing, bed mobility, and transfers, and was frequently incontinent of bowel with an indwelling urinary catheter. On the observed morning, the resident activated the call light at 7:15 AM for assistance to use the commode, but did not receive help until 8:39 AM, resulting in an involuntary bowel movement due to the prolonged wait. Interviews confirmed that only two direct care staff were working that shift for a census of 30, and the resident was often left waiting for extended periods due to insufficient staffing. Review of the facility's Device Activity Report and call light activity logs revealed numerous instances where call light response times exceeded the facility's policy of a 15-minute response, with some calls going unanswered for up to 138 minutes. These delays were not isolated to a single day but occurred repeatedly over a two-week period, affecting multiple residents. The facility's own policy required prompt response to call lights, and staff interviews confirmed that the expectation was to answer within 15 minutes, which was not consistently met. Further review of staffing schedules showed that the facility frequently scheduled fewer CNAs than required, particularly on weekends and overnight shifts. The Director of Nursing confirmed that the number of CNAs scheduled often did not meet the facility's own standards for adequate staffing. This chronic understaffing directly contributed to the inability to provide timely care and respond to residents' needs as required by both facility policy and regulatory standards.