F0725

E

Delayed Response to Call Lights and Toileting Needs Due to Insufficient Staffing

Chico, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ toileting needs, resulting in prolonged waits after call lights were activated. The CNA job description required CNAs to keep incontinent residents as clean and dry as possible, answer call lights promptly, and assist residents to and from the bathroom promptly. Resident 1, admitted with orthopedic aftercare following surgical amputation, difficulty in walking, and need for assistance with personal care, had a BIMS score of 14 and required partial/moderate assistance with transfers. Resident 1 reported that one evening after dinner and medications, a male staff member took him to the restroom; after he finished and pressed the call light, a female CNA entered, turned off the call light without assisting him out of the bathroom, and left. Resident 1 stated he then transferred himself to his wheelchair, waited approximately 45 minutes for staff to assist him back to bed, and ultimately self-transferred into bed after no one came.

Resident 2, admitted with spinal stenosis, difficulty in walking, and need for assistance with personal care, had a BIMS score of 13 and used a wheelchair, requiring partial/moderate assistance for toileting. Her bowel and bladder care plan identified risk for urinary tract infection related to insufficient fluid intake and urine retention secondary to avoidance of voiding in a brief, and directed staff to offer privacy, dignity, and prompt assistance when toileting. Resident 2 stated that staffing levels varied by day and staff, that there were not enough staff to meet her needs, and that the facility was often short staffed on day shift. She reported having to wait 30 minutes to an hour for assistance to use the restroom, leading to incontinent episodes that she felt interfered with her efforts to control bowel and bladder. She stated an agency staff member once told her to void in her brief, another CNA told her to “have fun” when she tried to go to the bathroom on her own, and that she almost daily had incontinent episodes due to waiting for toileting assistance, including an episode where she fell asleep in the bathroom while waiting about 30 minutes for help.

Resident 3, admitted with spinal surgery and arthritis and having a BIMS score of 15, used a wheelchair and was dependent on staff for all transfers. Resident 3 reported needing assistance to transfer from bed to wheelchair and that it took a while for staff to answer call lights, stating it seemed the facility was short staffed. She reported having incontinence episodes due to delayed staff response to call lights, stating that by the time staff arrived she had already voided before they could provide a bedpan. Facility records showed that on a specific date, two employees called out on the station where these residents resided, and a CNA was temporarily reassigned there and encountered numerous active call lights. Staff interviews described frequent short staffing, call-outs, and delayed responses to call lights, including an account that a CNA turned off a resident’s call light while the resident remained in the bathroom and that the resident waited a long time and had to get into a wheelchair and into bed independently. These events collectively demonstrate that residents requiring assistance with toileting experienced prolonged waits and unmet care needs due to insufficient and ineffective staffing coverage.