F0684

D

Failure to Monitor and Document Resident After Change of Condition

Mission Hills, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its change of condition (COC) monitoring policy and professional standards of practice for a resident with age-related osteoporosis, unspecified dementia, and essential hypertension. The resident, who had severely impaired cognitive skills for daily decision-making per the MDS dated 11/24/2025, complained of right hip pain on 2/9/2026 at approximately 2:40–2:45 p.m. A COC Evaluation documented the complaint of right hip pain, administration of Tylenol, and notification of the attending physician, who ordered a right hip x-ray. Facility policy required that after a COC, a licensed nurse assess the resident, document observations and symptoms, and chart each shift for at least 72 hours, including the date, time, and pertinent details of the incident and subsequent assessment in the nursing notes.

Record review and interviews showed that the resident’s COC status was not monitored or documented on the 11 p.m. to 7 a.m. shift on 2/9/2026, despite the requirement for every-shift monitoring for 72 hours. RN 1 acknowledged that the progress notes contained no documentation of monitoring for that shift and that she did not document her full assessment of the resident’s right lower extremity, including pain on palpation and the appearance of the right lower extremity. RN 1 and the DON both stated that care not documented is considered not done, and the DON confirmed there was no documented evidence of monitoring on the 11 p.m. to 7 a.m. shift and that RN 1 did not document the lower extremity assessment. The facility’s failure to assess and monitor the resident after the COC, as required by its policy, had the potential for the resident’s progress or decline to be missed and had the potential to negatively impact the resident’s health and safety.