F0558

D

Untimely Response to Resident Call Lights for ADL and Toileting Assistance

Bakersfield, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to answer resident call lights in a timely manner for three cognitively intact residents who required assistance with ADLs, particularly toileting. One resident, with a left femur fracture and care plan interventions directing staff to encourage call bell use and provide assistance with ADLs, reported using the call light for brief changes due to frequent urination from a diuretic and stated he could wait up to 40 minutes for staff to respond. He reported that when he requested assistance, staff would say they would notify someone else, but no one followed through, which made him angry. His MDS documented a BIMS score of 15 and a need for substantial/maximal assistance with toileting hygiene.

Another resident, also with a BIMS score of 15 and care-planned to use the call bell and receive assistance with ADLs including toileting hygiene, reported using the call light for restroom assistance and water and stated she had waited up to an hour for a response, timing the delay by looking at a clock across from her bed. She reported sometimes having to yell out until someone came and said the wait time made her feel like she was nothing. A third cognitively intact resident in the same room stated she would get up and go to the nurses’ station to find staff to help the second resident because the call light had been on so long. A CNA stated that when multiple call lights were on, she responded when she could and that during an emergency a resident’s call light might not be answered timely. Facility policies on resident rights and the resident call system required that residents receive services in accordance with their care plans, be treated with dignity and respect, and that staff respond to call system alerts in a reasonable and timely manner.