Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple days where staffing levels did not meet the facility's own staffing grid requirements. Staffing records reviewed with the Nursing Scheduler showed repeated shortfalls in both CNA and nurse coverage across various shifts, with some days being up to three staff short. These shortages were documented for several dates and shifts, despite the facility census indicating the need for more staff. Residents reported significant delays in receiving care, including long wait times for call light responses and missed showers. One resident stated she had not received a shower in over a week and often waited up to an hour for assistance, with staff sometimes turning off her call light without returning. Another resident, who required assistance with feeding due to quadriplegia, reported being denied food because staff did not have time to help him. Both residents indicated that these issues were ongoing and had been raised multiple times with facility management and in Resident Council meetings, but no improvements were observed. Direct observations by surveyors confirmed that staff frequently failed to respond to call lights, even when multiple staff members were present and the call lights were audible. On several occasions, staff were seen ignoring call lights while sitting at the nurse's station or walking by without responding. The facility's policy requires any staff member who sees or hears a call light to respond, but this was not followed. Additionally, the facility was unable to produce concern forms related to staffing or call light response issues raised in Resident Council meetings.