F0684

E

Failure to Provide Timely Incontinence Care and Call Light Response per Care Plans

Harker Heights, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide incontinence care, personal hygiene, and call light response in accordance with residents’ person-centered care plans and stated preferences. Multiple residents with bowel and bladder incontinence, self-care deficits, and cognitive impairment had care plans requiring staff to check and change them on rounds and as needed, keep their skin clean and dry, and conduct routine safety rounds. Despite these documented interventions, staff did not consistently perform timely rounds or respond promptly to call lights, resulting in residents remaining wet or soiled and waiting extended periods for assistance.

One resident with severe cognitive impairment, hemiplegia, dementia, and incontinence had a care plan for personal hygiene assistance, turning and repositioning on rounds and as needed, and incontinence care with check and change on rounds and as needed. Nursing notes documented a family complaint that this resident had been left soaking wet with urine for hours, although staff later documented the brief as dry. During observation, this resident was heard crying for help; when the call light was activated, no staff responded for 14 minutes and 9 seconds until a surveyor notified staff at the nursing station. No nursing staff were visible on the hall, and a housekeeper present in the area did not respond to the call light.

Another resident with intact cognition and bowel and bladder incontinence, whose care plan required incontinence care every shift and as needed, reported that staff did not check on him every two hours as needed and that sometimes no one checked on him all night. He stated he needed to be changed and repositioned and that he had previously voiced these concerns to nursing staff without improvement. A resident with vascular dementia, diabetes, and frequent bladder incontinence, whose care plan required monitoring for incontinence every 2–3 hours and as needed with application of skin barrier, reported that it took staff 30–45 minutes on different shifts to answer call lights for changing. Her responsible party stated that it typically took 45 minutes to an hour for call lights to be answered and that staff often said they would return but did not.

A resident with hemiparesis, frequent bladder incontinence, and a care plan requiring check and change on rounds and as indicated, toileting/incontinence care with assistance, and keeping skin clean and dry with barrier cream, reported that her call light was not answered promptly. She described an incident where she was wet, called for help, and waited one hour and 26 minutes for a CNA to respond. She also reported waiting 15–30 minutes for assistance to get up from the commode, despite needing help due to left leg weakness and pain. Another resident with paraplegia, bowel and bladder incontinence, and a history of sacral moisture-associated skin damage, whose care plan required check and change on rounds and as needed and keeping skin clean and dry with barrier cream, reported developing bed sores on her bottom from not being changed in a timely manner. She stated that the sore had been healing but broke out again when she was not changed, including an episode where she was not changed overnight when one CNA had the whole hall, and she sometimes waited 7–8 hours during night shifts in her own waste.

This same resident reported that when she pressed the call light, nobody came, and staff sometimes entered, turned off the call light, and said they would return when they had time, with actual waits of 30 minutes to an hour. Observation of her peri care revealed pink, dry skin breakdown around the sacrum and medial thighs. Multiple CNAs, an LVN, and an RN confirmed that call lights were expected to be answered immediately or within a few minutes, that rounds should be conducted every two hours, and that unanswered call lights and delayed incontinence care could lead to falls and skin breakdown. They acknowledged that not answering a call light for extended periods, such as over an hour, could be considered neglect. Despite a written policy and prior in-services emphasizing timely response to call lights and resident needs, staff interviews and resident/family reports showed that call lights were frequently unanswered for prolonged periods and that routine rounds and incontinence care were not consistently performed as care planned.