Failure to Perform Post–Change of Condition Assessments After Psychosocial Incident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care following a documented change in condition for one resident. The resident, who had generalized anxiety disorder, was cognitively intact and had documented capacity to understand and make medical decisions. An SBAR Communication Form dated 12/29/25 identified a change in condition related to the resident lending money to a CNA, and the care plan was updated the same day to address the resident’s risk for emotional distress and anxiety related to this incident. Progress notes from 12/29/25 documented that the ADON met with the resident, who reported having loaned $500 to a CNA due to the CNA’s reported financial struggles, and that only $250 had been repaid, causing the resident worry about the remaining amount. During interview and concurrent medical record review on 2/2/26, the ADON stated that, following a change in condition, nurses are required to conduct nursing assessments related to the change in condition every shift for 72 hours to address any potential complications from the specific event. Review of the resident’s progress notes showed no post-event nursing assessments or monitoring related to the change in condition incident involving the loan to the CNA. The ADON verified that these required nursing assessments were not completed. This failure posed the risk for changes in the resident’s psychosocial well-being not being identified and potentially delayed necessary care and treatment.
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