F0607

D

Failure to Implement Abuse Policy and Change of Condition Procedures After Resident Altercation

Eureka, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse prevention and management policy and its change of condition documentation procedures following an alleged altercation involving one resident. The resident was admitted with chronic systolic CHF, hypertensive heart disease, and generalized muscle weakness, and had no documented memory impairment. On 12/25/25, a health status note by a licensed nurse recorded that the resident was in an altercation with his roommate and would be on alert charting and monitored for changes or concerns. However, there was no documented immediate assessment of the resident for physical injuries or emotional distress, no timely change of condition (COC) entry, and no contemporaneous documentation of physician or family notification as required by facility policy and the facility’s COC lesson plan.

The DON later entered a COC note effective 12/25/25 but written on 12/26/25, documenting that the MD was notified and recommended monitoring, and stated she wrote it because she realized it had not been done and was needed to trigger alerts. Progress notes reflecting behavior monitoring for 72 hours after the alleged abuse incident, with effective dates of 12/27/25 and 12/28/25, were documented 48–72 hours late on 12/30/25. The DON confirmed that the 72-hour checks were incomplete, the assessments were not written to the expected standard, and there were no documented assessments immediately after the altercation. This occurred despite the DSD’s statement that nurses had been trained to chart assessments, COC, and 72-hour checks immediately after a resident was identified as a victim of an abuse allegation, and despite written policies requiring immediate assessment, MD and responsible party notification, care plan updates, and 72-hour monitoring documentation.