F0725

D

Failure to Provide Timely Call Light Response Due to Insufficient Staffing

Winona, Minnesota Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet a resident’s needs, resulting in repeated delayed responses to call lights and delayed care. The resident had intact cognition but significant physical impairments, including a history of cerebral infarction, hemiparesis/hemiplegia, unsteadiness on feet, limited range of motion on one side of the body, incontinence, impaired vision, and a history of falls. The resident’s care plan identified an ADL self-care deficit related to these conditions and specified that the resident required substantial to maximal assistance from one to two staff for transfers using a gait belt and walker or a PRN EZ Stand lift. The resident reported relying on staff assistance for transfers and toileting and stated that call lights were used primarily to get in or out of bed or to use the bathroom.

Over a 14-day period, the facility’s call light log for this resident showed that the call light remained active for more than 15 minutes on 38 occasions, with an average response time of approximately 27 minutes and 40 seconds. The longest delays, including multiple waits exceeding 40 minutes, occurred most frequently in the early morning hours between 5:00 a.m. and 9:00 a.m., with additional prolonged waits around midday and late afternoon to early evening. The resident reported that call lights often took about an hour to be answered, that staff had told him lights should be answered within 5–7 minutes, and that this did not occur in practice. He also reported that some call lights were turned off without assistance being provided and that he had experienced multiple episodes of incontinence related to these long response times.

Staff interviews further described inconsistent and delayed call light responses. A nursing assistant stated that call lights ideally should be answered within five minutes but acknowledged that during busy times such as early mornings, after lunch, and shift changes, residents might wait up to 30 minutes, and confirmed that this resident frequently complained about long waits. Another nursing assistant reported that staff should aim to answer call lights within 10 minutes but that this did not always happen and confirmed the resident’s frequent complaints. The DON acknowledged that this resident regularly complained of long call light response times, considered waits over 20 minutes to be a problem, and noted that the resident’s complaints typically involved waits over 30 minutes, which she reviewed with him using the call light log. The DON and nursing assistants were unaware that the resident had experienced incontinence episodes due to delayed responses, and the facility was unable to provide a call light response policy when requested.