F0689

D

Failure to Assess and Monitor Psychiatric Resident Leads to Resident-to-Resident Altercation

Glendale, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess, monitor, supervise, and provide necessary care for a newly admitted resident with significant psychiatric and behavioral issues, which resulted in that resident striking another resident. Prior to admission, a General Acute Care Hospital (GACH) psychiatric evaluation documented that the resident had a history of depression, anxiety, frustration, irritability, agitation, lack of motivation, dark thoughts, suicidal ideation with a plan to overdose, difficulty resisting urges to self-harm, unpredictability, impaired coping skills, and impaired insight, judgment, and impulse control. The GACH history and physical further indicated the resident had been admitted for increased agitation and anxiety. Upon admission to the facility, the resident’s diagnoses included paranoid schizophrenia, anxiety, and major depressive disorder.

Despite this extensive psychiatric history, the facility’s social services and nursing staff did not adequately review or incorporate the hospital records into the resident’s initial assessments or care planning. The Social Service History and Initial Assessment completed the day after admission left multiple psychosocial adjustment factors blank, including distressed mood, history of depression, history of suicidal ideation/gestures, anxiety, insomnia, use of psychotropic medications, history of drug/alcohol abuse, disruptive behavior, difficulty controlling behavior, agitation/aggression, and resistance to care. The Social Service Director later acknowledged she had not reviewed the hospital records before completing the assessment and was unaware of the resident’s documented dark thoughts, suicidal ideation, and increased agitation. The Interdisciplinary Team (IDT) meeting held the same day did not document or discuss the resident’s past behaviors from the GACH records, even though the IDT noted the resident would be admitted to psych services and monitored daily.

Nursing staff also failed to fully assess and plan for the resident’s behavioral risks upon admission. The admitting nurse reported receiving information from the GACH that the resident had increased aggressive behavior but did not ask for specifics, did not review the hospital records that accompanied the resident, and only initiated monitoring orders for anxiety, schizophrenia, and insomnia based on limited observations of repetitive anxious questions. Another nurse confirmed that the baseline care plan completed on admission noted psychotropic medication use but left mental health needs and behavioral concerns blank, and that there was no behavior management care plan in place before the incident. Psychiatric and psychological consults were not ordered until days after admission, and the resident had not been evaluated by a psychiatrist in the facility before the event.

On the morning of the incident, multiple staff members observed the resident walking up and down the hallway while waiting for a smoke break. Payroll staff and central supply staff both witnessed the resident suddenly stop behind another resident seated in a wheelchair and strike that resident on the upper back with an open hand, describing the contact as a hard smack with an audible sound. A CNA confirmed that the resident had rushed through breakfast and was pacing the hallway before the smoke break when the incident occurred. Following the event, a change of condition evaluation documented that the resident had allegedly physically abused another resident by slapping them and that the resident stated he did not know why he did it. The facility’s own policies required thorough evaluation of behavioral symptoms, identification of underlying causes, assessment of severity and safety risk, and immediate implementation of safety strategies, as well as completion of a baseline care plan within 48 hours of admission to meet immediate needs; however, these processes were not effectively carried out for this resident prior to the incident.