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F0684
D

Failure to Monitor Emotional Distress After Abuse Allegation

Riverside, California Survey Completed on 09-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to monitor a resident's emotional distress following an allegation of abuse and neglect that occurred at a general acute hospital prior to admission. The resident, who had diagnoses including postlaminectomy syndrome, diabetes mellitus, and fibromyalgia, reported to a treatment nurse that she felt neglected and dismissed by nursing staff in the emergency room during her hospital stay. Despite this report, there was no documented follow-up or monitoring of the resident's psychosocial condition after the allegation was made. Interviews with facility staff confirmed that residents are to be monitored for 72 hours after a change of condition, which includes significant changes in emotional or mental status. The facility's policy also requires nurses to notify the attending physician and document changes in the resident's condition. However, in this case, the required 72-hour monitoring and documentation were not implemented after the resident reported the incident, resulting in a failure to provide appropriate psychosocial support.

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