F0725

D

Delayed Call Light Responses Due to Insufficient Nursing Staff

Tabor, Iowa Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to respond to resident call lights in a timely manner, resulting in repeated delays in answering calls for assistance. One resident with no cognitive impairment and multiple serious diagnoses, including acute and chronic respiratory failure with hypoxia, vertebral fractures, and functional quadriplegia, reported that on the evening and overnight shifts it often took much longer than 15 minutes for staff to respond to call lights, and that on the overnight shift it had taken over an hour on at least one occasion. Call light system reports for this resident’s room over several days documented multiple instances where call lights remained unanswered for between approximately 19 and 50 minutes.

Another resident with moderate cognitive impairment also had multiple call light activations recorded as unanswered for more than 15 minutes, ranging from about 18 to 49 minutes. A third resident, with moderate cognitive impairment and a history of stroke, multiple psychiatric diagnoses, and multiple falls and a fracture related to falls prior to admission, had a care plan identifying high fall risk with interventions including keeping the call light within reach and prompt response to all requests for assistance. However, call light reports for this resident showed numerous delays between approximately 16 and 47 minutes. This resident stated she felt there was not enough staff because she had to wait a long time for call lights at times. CNAs and an RN acknowledged that call lights sometimes took longer than 15 minutes to answer, and the DON stated the expectation was that call lights be answered in under 15 minutes, while the written call light policy did not specify a response time.