F0725

E

Insufficient Nursing Staff Leading to Unmet Care Needs and Prolonged Call Light Response Times

Evansville, Wisconsin Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ assessed needs and care plan interventions, resulting in unmet care needs and prolonged call light response times. The facility’s own “Sufficient Staffing” policy requires adequate nursing staff with appropriate competencies, daily review of staffing patterns, and adjustment of staffing based on census and resident acuity. Despite this, multiple residents and staff reported that there were not enough CNAs and that essential care tasks were not completed because staff were too busy. Surveyors directly observed long call light wait times on the unit, with call lights remaining unanswered for extended periods while staff were either not present on the hall or engaged in other activities.

One cognitively intact resident reported waiting up to 45 minutes for call lights to be answered and described staff entering the room, stating they would return, and then not coming back for more than an hour, leaving needs unmet. Another cognitively intact resident with quadriplegia and physician orders and care plan interventions for daily active assisted ROM to the bilateral lower extremities stated that CNAs did not perform the ROM exercises as ordered because they were too busy. During a surveyor observation of this resident’s call light, staff entered the room within a few minutes, turned off the call light, told the resident they would notify a CNA about the need for incontinent care, and then left; incontinent care was not provided until approximately 24 minutes after the initial call light activation. CNAs later confirmed they had not completed the resident’s ROM exercises that day due to being too busy.

Another resident with multiple sclerosis, paraplegia, a stage 4 sacral pressure injury, and a care plan requiring turning and repositioning at least every 1–2 hours was observed lying on her back in the same position over several hours, from early morning through early afternoon. CNAs assigned to her care acknowledged that she should be repositioned every 2 hours and admitted that she had not been repositioned during the shift until cares were provided around 2:00 PM, stating they did not always have time to reposition her. A different resident reported that there was one CNA for 20 residents and described waiting up to 1.5 hours for assistance to use the bathroom, resulting in an accident that made the resident feel terrible, humiliated, and disrespected. Surveyors also documented multiple call lights active for 10–32 minutes before being answered, including one instance where a nurse manager walked past a room with an active call light without responding.

A further cognitively intact resident with lymphedema, fibromyalgia, chronic pain, morbid obesity, and a care plan requiring two staff for all cares and use of a Hoyer lift to and from the commode reported that there were not enough staff, especially on evening and night shifts. This resident stated she had to wait up to an hour for staff to answer her call light or assist her off the commode, and that prolonged time on the commode caused numbness in her right hip and leg and purple discoloration on the backs of her legs. She also reported sitting on a Hoyer sling all day, causing painful indentations, and stated that when she complained, staff became sarcastic, so she stopped voicing concerns. CNAs interviewed by surveyors stated there were not enough staff to complete all resident care needs, specifically citing that repositioning, ROM, and oral care often did not get done because there was too much to do, and that they were unable to take breaks due to workload, further confirming that staffing levels were insufficient to meet residents’ care plan requirements and daily needs.