F0684

E

Failure to Monitor and Document Resident After Change in Condition

North Hollywood, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to follow its change in condition (COC) policy and professional standards of nursing practice by not ensuring that a resident was monitored and documented every shift for at least 72 hours after a documented COC. The resident, admitted with diagnoses including asthma, depression, and overactive bladder, had a Minimum Data Set indicating moderately impaired cognitive skills for daily decision making. On 1/18/2026, a Change in Condition Evaluation documented that the resident complained of a burning sensation during urination. Facility policy required licensed nurses to document each shift for at least 72 hours when there is a change in the resident's condition, and both RN 1 and the DON stated the resident should have been monitored every shift during this period.

During interview and record review, RN 1 identified that there was no documented evidence of monitoring on five specific shifts following the COC: the 11 p.m. to 7 a.m. shift on 1/18/2026; the 11 p.m. to 7 a.m. shift on 1/19/2026; the 7 a.m. to 3 p.m. and 11 p.m. to 7 a.m. shifts on 1/20/2026; and the 7 a.m. to 3 p.m. shift on 1/21/2026. RN 1 stated that care not documented is considered not provided and that failure to document monitoring could result in a failure to identify worsening symptoms. The DON confirmed there was no documented evidence of monitoring on the identified shifts and acknowledged that the facility failed to ensure the resident's health status was monitored every shift following the COC, as required by the facility's Change in Condition policy.