F0607

D

Failure to Implement Abuse Assessment and 72-Hour Monitoring After Alleged Incident

Fortuna, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to implement its abuse prevention and management policy for one resident following an alleged abuse incident. Resident 1, admitted in October 2025 with diagnoses including encounter for palliative care, acute chronic systolic congestive heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set dated 1/10/26 indicating slight memory impairment. After an allegation of abuse on 1/9/26, the DON stated she expected licensed nurses to complete and document a change of condition assessment, including a physical and psychosocial assessment, document when the physician and family were notified, update the resident’s care plan, and initiate 72-hour monitoring. However, record review and the DON’s concurrent interview confirmed there was no documented assessment or progress notes and that the required 72-hour monitoring and alert charting were not completed.

The facility’s own Abuse Reporting and Documentation lesson plan directed licensed nurses to complete an assessment and skin assessment of the alleged victim, notify the MD, add the resident to alert charting for 72 hours with appropriate monitors for increased distress, and document psychosocial status every shift, with Social Services documenting psychosocial status daily and the IDT promptly reviewing allegations. The facility’s Abuse Prevention and Management policy, revised 5/30/24, required that the resident be assessed by a licensed nurse for any physical injuries or emotional distress and that the physician be notified and treatment provided as ordered. The DON confirmed that social services 72-hour checks were lacking and that there was no assessment documented or progress notes for Resident 1 following the alleged abuse incident.