Failure to Provide Sufficient Nursing Staff Resulting in Excessive Call Light Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by repeated excessively long call light response times for seven out of eight sampled residents. Call light activation logs revealed that residents frequently waited between 22 minutes and over two hours for assistance with essential care needs such as toileting, repositioning, medication administration, and help with medical equipment. These delays were documented across multiple days and shifts, affecting residents with significant medical conditions and dependencies, including recent surgeries, infections, wounds, amputations, and severe mobility impairments. Residents directly reported their experiences of prolonged waits, with some stating they had to remain in soiled briefs, wait for pain or nausea medication, or attempt to manage medical equipment themselves due to staff unavailability. Observations further confirmed unmet care needs, such as a resident's urinal being left full and a strong urine odor in the room. Staff interviews corroborated these findings, with nursing assistants, nurses, and the staffing coordinator acknowledging frequent short-staffing, reliance on agency staff, and challenges in maintaining adequate coverage, especially after reopening a previously closed wing. The facility's own assessment and staffing review processes were based on state minimum standards and resident acuity, but these measures were not sufficient to ensure timely care. Staff described being pulled from their assigned roles to cover shortages, leading to further strain and missed breaks. Agency staff were often used to fill gaps, but their reliability and adherence to facility expectations were inconsistent, with some agency staff being sent home for not responding to resident needs. The Director of Nursing confirmed ongoing difficulties in scheduling and meeting the facility's expectation that call lights be answered within 20 minutes.