Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, as evidenced by prolonged call light response times and unmet care needs. The facility census showed 73 residents, and the facility assessment stated staffing was adequate based on resident population, acuity, and regulatory requirements. However, multiple residents reported waiting extended periods after activating call lights, including reports of waiting 30 minutes to an hour or more for assistance, particularly with toileting and transfers. One resident with a history of falls, dizziness, and passing out stated that call lights sometimes took an hour to be answered. Another resident council president reported frequent staffing and call light concerns, including waiting from 11:00 PM to 12:00 AM for help to the bathroom, resulting in accidents and describing the experience as humiliating and painful. Staff interviews corroborated these concerns and described chronic understaffing. An LPN reported that on one occasion there were only two CNAs for 50 residents, leading to missed showers and long waits for assistance, and that a resident complained of waiting over an hour to go to bed and have a call light answered. Another LPN stated there were not enough nurses and staff to complete required tasks or charting, and that the patient-to-nurse ratio made it impossible to provide adequate help. A CNA reported daily CNA call-ins that were not always replaced, especially on second shift, resulting in residents waiting longer to be changed and cleaned up and increased frustration for some residents. During observation, a resident with a flaccid arm was seen waiting with a call light on for help with incontinence care and reported having accidents while waiting. The DON acknowledged awareness of call light concerns and agreed that 30 minutes was too long for someone to be expected to hold their bladder, noting that staff call-offs increased during that time of year.
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