F0740

D

Failure to Assess and Address Behavioral Health Needs After Alleged Abuse Incident

Los Angeles, California Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with depression and chronic anxiety received necessary behavioral health care and services following an alleged abuse incident. The resident was admitted with diagnoses including HTN, hyperlipidemia, depression, a colostomy, and a gastrostomy, and had intact cognition and decision-making capacity. Physician orders dated 10/23/2025 included a psychology consult and treatment as needed, and the resident’s care plan identified a psychosocial well-being problem related to a language barrier, with interventions including consultations with pastoral care, social services, and psych services.

On 1/1/2026, the resident reported an allegation of abuse involving a CNA on the night shift. According to nursing progress notes, the resident stated that the CNA woke her aggressively, threw towels on her chest and colostomy site, pulled and turned her while providing care, and made arm gestures with two closed fists while telling her that if she spoke up about what happened she would be hit. The resident reported feeling afraid of this CNA. Subsequent physician documentation on 1/5/2026 noted that the resident, who had a chronic anxiety disorder per her husband, experienced increased nighttime anxiety and was afraid to fall asleep after this interaction. A progress note on 1/8/2026 documented that the resident stated she did not feel safe.

Despite these documented changes in the resident’s emotional and behavioral status, the facility did not complete a behavioral assessment or change-of-condition assessment related to the 1/1/2026 incident. The Social Services Supervisor confirmed that trauma assessments are to be done on admission, quarterly, and at change of condition, and acknowledged that no behavioral assessment was done for the resident’s change in condition on 1/1/2026 and that there were no psychologist progress notes for the resident. The MDS Coordinator also stated there were no behavioral assessments done for the resident for 1/1/2026. The Quality Assurance Nurse described that, in general, an abuse allegation should trigger emotional distress monitoring, psych evaluation, social services consultation, and care plan updates when a resident continues to feel unsafe, but the record showed the resident’s increased anxiety and expressed lack of safety were not identified and addressed through care-planned behavioral health interventions. The facility’s own policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning require identification, documentation, and interdisciplinary evaluation of new or changing behavioral symptoms and revision of the care plan when there is a significant change in condition, which did not occur in this case.

During interviews, the Social Services Supervisor reported that the resident had made remarks about certain people of different ethnicities being loud, harmful, and unfriendly, and that the resident was not comfortable with certain staff of a different ethnicity, suggesting possible past trauma, but no related behavioral or trauma-focused assessment was documented after the incident. The DON stated she was not aware that the resident had reported not feeling safe on 1/8/2026 and indicated that the nurse should have notified the physician of this statement. Overall, the facility failed to recognize and assess the resident’s increased anxiety and fear following the alleged abuse, failed to initiate required behavioral assessments or a documented change-of-condition process, and failed to implement or document appropriate behavioral health and psychological services as outlined in the resident’s orders and the facility’s policies.