F0656

D

Failure to Care Plan for Alleged Abuse Incident

Fullerton, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop a comprehensive care plan addressing an alleged abuse incident for one resident. The facility’s care planning policy, revised in 2/2021, requires the IDT to develop a comprehensive care plan for each resident. The resident was admitted on an unspecified date and had an H&P dated 10/17/25 indicating the resident did not have the capacity to understand and make decisions. On 1/9/26, a progress note documented that police arrived around noon after the resident’s wife reported to them that the resident had been abused, bruised, and burned. An eINTERACT Change in Condition Evaluation dated 1/9/26 documented right hand discoloration. Progress notes from 1/9 and 1/13–1/15/26 showed that Social Services provided psychosocial support to the resident.

Further review of the medical record showed there was no documentation of psychosocial support from 1/10–1/12/26 following the alleged abuse incident on 1/9/26, and no care plan was developed to address the alleged abuse. During an interview and concurrent record review on 2/3/26, an RN confirmed there was no care plan related to the alleged abuse and stated that a licensed nurse should have created one so staff could monitor the resident and have goals and interventions in place. In a separate interview on 2/3/26, the DON also verified that no care plan was developed for the alleged abuse, explaining that staff did not create an alleged abuse care plan because the allegation was unsubstantiated, no harm was identified, and there was no change in condition. The DON stated that psychosocial support was provided daily by the social worker and that a care plan was completed for the resident’s hand discoloration, but not for the alleged abuse itself.