Health inspection·June 20, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff was available to answer a resident's call light for one of two residents (Resident 1), when the resident requested assistance to go to the bathroom for toileting needs. This failure had the potential for the resident to be incontinent and also cause psychosocial harm. Findings: During a review of the facility document titled, Nursing Staff Sheet (NSS), dated 4/28/24, the NSS indicated for 3-11 shift (afternoon), the census was 88 and seven certified nursing assistants (CNAs) were scheduled for patient care. The NSS further indicated, each CNA had approximately 12 to 13 residents each to care for. During an interview on 5/13/24 at 10:43 am with the director of nursing (DON), the DON stated, We are not understaffed .We currently do not have any staffing waivers . In this facility the expectation is that anyone that works here and sees or hears a call light they are expected to go in and at least see what the resident needs . During a review of Resident 1's Face Sheet, dated 5/13/24, the face sheet indicated, Resident 1 was admitted on [DATE], with diagnoses that included, hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) following acerebral infarction (stroke-disrupted blood flow to the brain) affecting left non-dominant side. During a review of Resident 1's Minimum Data Set (MDS-assessment of current health conditions), dated 5/8/24, the MDS indicated, a BIMS (brief interview of mental status) score of 15, which indicated intact cognition (alert mental processes), no behavioral issues, with upper and lower impairment on one side (left of the body), continent of bladder but requiring maximum assistance for toileting. During a review of Resident 1's Care Plan (CP), revised 9/21/23, the CP indicated, Resident 1 had impaired functional abilities related to left hemiparesis, full dependence on toileting, potential elimination concerns related to hemiparesis with interventions including but not limited to, answer all call bells promptly to ensure continued continence of bowel and bladder; and scheduled/habit toileting program: upon awakening, before and after breakfast, before and after lunch, before or after supper, at bedtime, and during the night if resident is awake. During a concurrent observation and interview on 5/13/24 at 11:53 am with Resident 1 inside the Page 1 of 2 055256 055256 06/20/2024 Lompoc Valley Medical Center Comprehensive Care Ce 216 North Third Street Lompoc, CA 93436

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's room, Resident 1 was sitting on a wheelchair, and a urinal (plastic container to urinate in) was hanging on a bedside rail. Resident 1 attested to an incident on 4/28/24 and stated in part, They seem to treat people like cattle here. When they ignore my call light, I went on my wheelchair to the nurses station and told (name of licensed nurse 1 -LN1), I need help going to the bathroom. (Name of LN1) said, I have an assigned CNA and to go back to my room and wait. But I told (name of LN1) I need to go but she keep arguing with me about their staffing. One CNA has like 17 people to care for and they don't help each other out, the supervisors just sits and don't help, and since my time here, their answering of the call light is a constant problem. I stopped going to my care meetings as it's just a big show, I am going to be rude when they treat me like a piece of meat, I have started taking notes regarding response time, if I am in bed, I can use the urinal, but if I am on the wheelchair I can't. My left arm and leg has been affected by stroke and it is hard for me to use the urinal. During an interview on 5/13/24 at 12:26 pm with CNA1, CNA1 stated, .I was on dinner break that night . the resident was upset about staff getting him to the bathroom . his biggest complaint was that the light was on and nobody got there quick enough for him . I know he uses the urinal, but I don't think he uses it when he is in his chair. When he is in the chair, he uses the call light then we take him to the bathroom. We use the easy stand with him to get him to the toilet, and off the toilet. On the weekends we can be shorter staffed, on the weekends there should be ten CNA's, and sometimes people call in, I stayed that day for a double shift and had him (Resident 1) the entire time. As far as the time to get to a room with a call light on I do not know an actual time frame .Usually I would have ten residents, but it can change due to the census .that night he was in his chair not the bed when he used the call light . 055256 Page 2 of 2