F0725

F

Insufficient Staffing Leading to Delayed Call Light Response and Incontinence Care

Bridgeport, Illinois Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely response to call lights and incontinence care. One resident with morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis was care planned as occasionally incontinent of bowel and bladder, with interventions including check and change every 2–3 hours, PRN, application of barrier cream after each incontinent episode, and prompt call light response. During observation, this resident’s incontinence brief was found saturated with urine, and the buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots, which the wound nurse identified as moisture-associated skin damage. The resident reported that staff applied cream at times but was unsure how often, and also stated that it sometimes took a long time for staff to answer the call light, recalling a wait of about an hour and a half on one occasion.

Another resident with myasthenia gravis, diabetes, heart disease, unsteadiness on feet, neuropathy, and atrial fibrillation was cognitively intact and dependent on staff for toileting, with a care plan directing check and change every 2–3 hours and PRN and prompt call light response. A family member reported that the facility was short staffed on weekends at times. The resident’s cognitively intact roommate stated that on one occasion it had taken an hour for staff to answer the call light after the resident had soiled himself, and that the CNA explained there were only four CNAs working at the time. A third cognitively intact resident, dependent on staff for toileting and always incontinent of bowel and bladder, was care planned for barrier cream and perineal cleaning with each incontinent episode and prompt call light response. This resident reported that when there was not enough staff, call lights were not answered timely, resulting in long waits to get up in the morning and waits of a couple of hours for incontinence care at night.

A fourth cognitively intact resident, always incontinent of bowel and bladder and care planned for prompt call light response, stated that when staffing was low, she had to wait 30 to 45 minutes for care. Multiple CNAs reported that there were not enough staff to meet residents’ needs timely, particularly on the 2 pm–10 pm shift and on weekends, noting that around 4 pm they must get residents ready for supper, answer call lights, and that call lights were not always answered timely. Staff described having four CNAs on weekends, one per hall, and difficulty providing timely assistance to residents requiring two-person assist, which delayed getting such residents to bed after dinner and delayed call light response. Another staff member stated that call lights were answered as timely as possible but acknowledged that with many residents needing two-person assist and nurses occupied with medication pass, call lights could be delayed and residents might sit longer after incontinence episodes before care was provided. While some nursing leadership staff stated they believed staffing was sufficient and that call light response had improved, one RN acknowledged that the 2 pm–6 pm period was very busy and that they could use a couple more CNAs, and the administrator reported that staffing had not changed since the last survey.