F0684

D

Failure to Perform Required Post–Change in Condition Monitoring After Verbal Abuse Incident

Seal Beach, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required nursing assessments and monitoring following a resident’s change in condition related to an incident of verbal abuse. The facility’s Abuse and Neglect – Clinical Protocol policy stated that staff and the physician would monitor individuals who have been abused to address issues regarding their medical condition, mood, and function. The resident involved had diagnoses including anxiety disorder and depression, was documented as cognitively intact, and had previously expressed increased anxiety about having another heart attack. After a dietary aide was observed yelling at the resident, a Change in Condition Evaluation documented that the resident experienced increased anxiety and brief situational emotional distress related to the altercation, and then returned to baseline with reassurance.

The resident’s care plan was updated with a problem addressing the verbal abuse incident, including an intervention to monitor the resident for 72 hours for changes in routine and symptoms of distress. Facility staff, including an LVN and the ADON, stated that following a change in condition, nursing staff were supposed to assess and monitor the resident every shift for 72 hours, focusing on the change in condition to ensure proper interventions and to notify the physician if needed. The ADON stated that the purpose of the follow-up assessments for this resident was to ensure the resident felt safe and comfortable and to assess for any pain. The ADON verified that the resident was not monitored following the verbal abuse allegation on the morning of 2/10/26 and that all assessments were missed on 2/11/26, and the DON confirmed these findings.