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 on three of four units, as evidenced by multiple interviews, grievance and call light log reviews, and direct observations. One resident, who was cognitively intact and dependent for toilet transfers, reported long wait times for call light responses and meals. The resident's representative and roommate confirmed that the resident was sometimes left sitting in feces due to extended wait times, and that the call light and phone were often placed out of reach. Observations confirmed the resident was left unable to access the call light and phone, and grievance logs documented similar concerns from the resident's family. Call light logs showed multiple instances of excessive wait times, including waits of up to 84 minutes. Additional interviews with residents during a council meeting revealed that call lights were often turned off by staff with promises to return, but assistance was not provided in a timely manner. One resident reported waiting 73 minutes for a call light to be answered. Staff interviews confirmed frequent understaffing, with reports of only one CNA on a locked unit and two for the rest of the building at times, resulting in residents being left soaked in the morning. CNAs described situations where one CNA was responsible for up to 27 residents at night, and call lights remained unanswered for over an hour. The DON acknowledged the lack of a facility policy on call light response times and confirmed ongoing issues with staffing and call light response.