Delayed Call Light Response Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two of five sampled residents. One resident, who is cognitively intact and dependent on staff for toileting and hygiene, reported using the call light for assistance with water and changing, and stated that the shortest wait time experienced was 30 minutes, with waits extending up to an hour. This resident expressed dissatisfaction with the wait times, indicating a desire to leave the facility. Review of the resident's care plan confirmed the need for assistance and the intervention to encourage use of the call light. Another resident, also cognitively intact and at risk for ADL/mobility decline, reported waiting up to 45 minutes for a breathing treatment after using the call light, leading the resident to go directly to the nurses' station for assistance. This resident's care plan included interventions for respiratory care and medication administration as ordered. Staff interviews revealed that CNAs and LVNs were frequently assigned high numbers of residents, especially during staff call-offs, with CNAs caring for up to 18 residents and LVNs for up to 32 residents per shift. Staff reported that short staffing occurred multiple times per week, making it difficult to meet resident care needs and resulting in missed showers and breaks. The facility's policy and procedure for call lights was requested but not provided during the survey.