Insufficient Nursing Staff and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly during October, as evidenced by staffing records, staff interviews, and call light response observations. Review of PBJ (Payroll Based Journal) data from July through December showed the facility triggered for one-star staffing and excessively low weekend staffing, with October schedules and daily staffing postings revealing that on 21 of 31 days, CNA staffing did not meet the facility’s own deemed appropriate numbers, and all four weekends were understaffed. Nurse and Certified Medication Assistant staffing was also below the facility’s targets on six days, four of which were weekends when CNA staffing was also short. Staff interviews, including CNAs, an LPN, a CMA, and the scheduler, consistently cited frequent call-ins as a cause of short staffing and acknowledged that nurses had to assist with CNA duties, that staff got behind, and that residents were affected when shifts were short. Surveyors directly observed delayed responses to resident call lights, further demonstrating the impact of insufficient staffing on resident care. One resident’s call light remained activated for 16 minutes while multiple staff members walked past the room before anyone entered. In another instance, a CNA entered a resident’s room after a call light was activated, was told the resident needed to use the bathroom, turned off the call light, instructed the resident to wait, and left; the resident reactivated the call light 10 minutes later, and it was approximately five minutes more before another staff member entered the room. The Nursing Home Administrator acknowledged staffing challenges in October and November and stated that nurse managers were present on weekends providing care, but the facility did not provide additional information to address the surveyor’s concerns about low staffing or the delays in answering call lights.
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