Failure to Complete 72-Hour Change-in-Condition Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete required 72-hour monitoring and documentation following a change in condition for one resident after an altercation. The resident, who had dementia, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, was admitted with significant mental health diagnoses. His MDS dated 11/4/25 showed a BIMS score of 11, indicating moderately impaired cognition, and documented that he felt down, depressed, or hopeless nearly every day during the assessment period. On 1/11/26 at 3:45 p.m., a progress note documented that the resident was struck twice in the left front shoulder with a closed fist by another resident, constituting a change in condition that triggered the facility’s change in condition process. Subsequent documentation showed that on 1/12/26 at 1:19 p.m., an IDT note recorded the resident stating, "I don't know if I am hurt or just upset," and on 1/13/26 at 8:35 a.m., a progress note indicated he remained upset about the altercation and was very worried the other resident would continue to bother him. During an interview and record review on 2/26/26 at 11:45 a.m., the DON reviewed the resident’s documentation following the 1/11/26 altercation and acknowledged that although a change in condition had been initiated, continuous 72-hour monitoring notes were not charted for every shift after the incident, so completion of the monitoring could not be verified. This failure occurred despite the facility’s policy titled "Change in Condition," effective 8/25/22, which required a licensed nurse to document each shift for at least 72 hours when there is a change in a resident’s condition.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.