F0558

D

Failure to Timely Respond to Call Light and Provide Incontinence Care

Stockton, California Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not responding to a call light in a timely manner. Resident 1, who had spinal stenosis, difficulty walking, generalized muscle weakness, ADL self-care performance deficits, and was at risk for bowel and urinary incontinence, relied on staff assistance for toileting and hygiene. On the survey date, the call light for the shared room of Resident 1 and Resident 2 was observed to be on at 11:37 AM and remained unanswered through multiple observations at 11:40 AM and 11:44 AM, despite staff, including a licensed nurse, being present at the nurses’ station and not responding.

During a joint observation and interview in the room at 11:46 AM, the call light for Resident 1 was still unanswered. Resident 2 reported that staff did not come to answer the call light and that both residents did not get the attention they needed. Resident 2 stated that Resident 1 wore incontinent briefs that would get wet and needed changing, and that when Resident 1 asked staff to change him, they would say they would come back but did not. Resident 1 stated he had not been changed since the previous night and sometimes waited 30 minutes for his call light to be answered. Resident 2 confirmed that staff had not come to change Resident 1’s brief since the previous night and that he did not know the name of the CNA assigned to their care.

Further observation at 11:54 AM showed a CNA passing by the hallway in front of the room without responding to the call light. The call light was finally answered at 12:01 PM by the Administrator, who then sought assistance from staff and contacted the licensed nurse. Interviews with the Director of Staff Development and the Administrator confirmed that the facility’s expectation and policy were for call lights to be answered within a few minutes and for any staff member to respond, and that residents, including Resident 1, were to be checked and assisted with toileting and incontinence care regularly and as needed. Resident 1’s care plans directed staff to encourage use of the call bell for assistance, respond promptly to toileting requests, assist with cleansing after bowel movements, and maintain proper perineal hygiene, as well as to promote dignity by promptly responding to toileting assistance requests. These documented expectations contrasted with the observed prolonged, 24-minute delay in answering the call light and the reported lack of timely incontinence care for Resident 1.