F0658

D

Failure to Complete Abuse-Related Skin Assessment and 72-Hour Monitoring per Professional Standards

Santa Rosa, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing services met professional standards for assessment and documentation following an abuse allegation involving Resident 1. Resident 1, who had COPD, left-sided hemiplegia, and major depressive disorder and was cognitively intact per a BIMS score of 13, reported alleged physical abuse on 12/18/25, stating that someone grabbed her right arm. An SBAR change-of-condition note documented skin discoloration on the right forearm with intact skin, no swelling, and no pain. However, no detailed skin integrity assessment was completed at that time to describe the bruising in terms of size, exact location, and characteristics, despite facility policy requiring detailed observations and the DON’s expectation that a skin integrity assessment be completed when the bruising was first reported. A skin/wound note was not entered until 12/21/25, and during a later observation on 1/05/26, two distinct bruises were noted on the lateral aspects of Resident 1’s right upper and lower arm, with specific measurements and color changes that had not been previously documented.

The deficiency also involves the facility’s failure to complete ordered 72-hour monitoring every shift following a change in condition for Resident 2. Resident 2, who had DM, vascular dementia with behavioral disturbances, and major depressive disorder and was cognitively intact per a BIMS score of 13, was observed on 12/17/25 to have increased agitation, physical aggression, wandering, and entering other residents’ rooms. An SBAR change-of-condition note documented these behaviors and indicated that 72-hour monitoring was initiated, and the care plan reflected that the resident was exhibiting adverse behaviors affecting physical well-being, safety, and aggression toward staff and other residents, with 72-hour monitoring started. Facility documentation and the DON’s review showed that required 72-hour monitoring notes were not completed every shift as expected.

Record review revealed that for Resident 2, there was no evidence that 72-hour monitoring was completed by nursing staff on any shift on 12/18/25, nor on AM, PM, and NOC shifts on 12/19/25, and NOC shift on 12/20/25. The DON stated that her expectation was that licensed nursing staff complete 72-hour monitoring every shift, resulting in nine progress notes over the monitoring period, but confirmed that only two notes were completed on 12/20/25. Facility policies required that all services provided to residents be documented in the medical record and that charge nurses ensure care is provided according to the care plan and that nurses’ notes reflect that the care plan is being followed. These omissions in assessment and monitoring documentation for both residents constituted failures to meet professional standards of quality and facility policy requirements.