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Based on observations, medical record review, document review, staff and family interviews and review of the facility's policy, the facility nursing staff failed to ensure that patients' call lights are answered promptly and the nursing care needs of one of the eight sampled patients (Patient 3) was being met. This deficient practice had the potential to affect all of the 40 current patients who are receiving service at the facility.

Findings Include:

Review of the facility's "Grievance files" revealed documentation that the facility received a grievance from Patient 3's family member (F3) on 06/21/19, which claimed the patient had called for assistance with her call light "approximately 7 times" and did not receive the help needed to meet her hygiene needs and that the patient had "sat in the chair with a soiled brief for at least 2 hours" without receiving assistance from the nursing staff. Patient 3's discharged medical record showed an admission date of 06/04/19 with a diagnosis of acute respiratory failure and a discharge date to another hospital on 06/26/19. The grievance file documents showed that Staff C, the Director of Quality and Risk Management (DQRM) responded to F3 by certified mail on 06/26/19 in which she acknowledged the issues raised in the complaint and indicated that efforts would be made to improve the service.

During an interview on 11/22/19 at 11:04 AM, Staff D, Registered Nurse (RN) recalled providing care for Patient 3, but was unaware of any concerns raised by the family about the care provided. Staff D stated that alerts from the patients' call lights are displayed at all four nurses' stations. The staff try to respond within five minutes; however, Staff D, did not know if the facility had a policy that provided the staff with the time parameters for responding to the patients' call lights. Staff D further stated that every effort is made to meet patients' needs in a timely manner, and that "...there is enough staff available to be to respond in a timely manner."

During an interview on 11/21/19 at 11:16 AM, current Patient 9's family member (F9) stated that when Patient 9 activated the call light, there was a delay of 45-50 minutes before the staff responded. F9 explained that this delay occurred when Patient 9 was newly admitted. They had not experienced any problems after they reported the issue to the Staff B, the Chief Nursing Officer (CNO).

During an interview on 11/21/19 at 11:26 AM, current Patient 10 stated that sometimes there was a delay before the staff responded to her call light, but the patient could not provide the length of time for the delayed responses.

Review of the facility's "Compliance/Grievance Record" for the third quarter of 2019 showed that two of the six complaints filed related to nursing staff's delay in responding to patients' call lights.

During an interview on 11/22/19 at 10:40 AM, Staff B, CNO stated that she was aware of the patients' concerns about the delays in the staff's response to their call lights. Staff B, CNO stated that the hospital had developed a "Call light Response Team," but had no documentation of the plan or its implementation. Staff B, CNO stated that while a team of staff led by her met and discussed the issues surrounding patients' reports of delays in the staff's response times to their call lights, the discussions were not documented, and a performance improvement plan (PIP) was not formalized.

During an interview on 11/22/19 at 1:30 PM, Staff C, DQRM and Staff A, Chief Operation Officer (COO) stated that the hospital's call system includes monitors in each of the four hallways, and at each of the four staffed nursing stations to alert all staff that a response to a call light is needed. The only way to silence the call light alarm is to enter the patient's room, respond to patient's need, and then cancel the alarm. Each staff member has a "backup buddy" assigned to them whose purpose is to respond to the call light if the primary staff member assigned to the patient does not respond to the patient's call light. Staff C also stated that while the quality assessment and performance improvement (QAPI) team reviews and addresses each patients' complaint/grievance and provides a written response to the complainant about the actions taken, there was no action taken to educate the staff regarding F3's complaint about delay in call light response time.