F0580

D

Failure to Notify MD and Resident Representative After Alleged Physical Restraint

Mission Hills, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the physician and resident representative of a significant change in condition and alleged abuse involving one resident. The resident was an individual with dementia and Alzheimer’s disease, admitted with diagnoses including muscle weakness and gait and mobility abnormalities. Assessments showed the resident had a high fall risk score of 21, lacked capacity to understand and make decisions, rarely understood and was rarely understood, and required varying levels of staff assistance for ADLs such as showering, dressing, toileting, oral hygiene, and personal hygiene. The resident’s care plan included education of staff about types of abuse, including physical restraint, prevention measures, reporting requirements, and respect for resident rights.

On the night in question, during the 11 p.m. to 7 a.m. shift, the resident became restless and was heard chanting or yelling intermittently in a language not understood by the LVN on duty. The LVN asked the CNA assigned to the resident, who spoke the same language, what the resident was saying, and the CNA responded that the resident always did that. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room and then left, and the resident’s vocalizations continued and worsened. Later, at approximately 2:50 a.m., the LVN entered the resident’s room, observed the blanket on the floor, and when picking it up noted that the resident’s wrists were bound together in front with a scarf tied in a firm figure-eight pattern multiple times, with no apparent wiggle room for the resident to move her hands. The LVN reported that the resident appeared relieved and moved around as if to draw attention to the bound wrists. The LVN took a photograph of the bound wrists and then untied the scarf around 3 a.m.

Subsequent interviews and record reviews showed that this incident was treated by facility leadership as alleged physical abuse and use of a physical restraint, and as a change of condition that should have triggered formal documentation and notifications. The DON and RMN both stated that an allegation of abuse is considered a change of condition and that a Change of Condition (COC) form should have been initiated on the date of the incident to communicate with all staff, the MD, the IDT, and the family, and to start 72‑hour monitoring. However, there was no COC documented for the date of the incident, and the RMN confirmed there was no COC entry for that date in the resident’s record. The MD reported being notified the next morning about the resident having a scarf-like object tied over her wrists and increased confusion, but the RMN stated there was no documentation that the MD was notified on the date of the incident. The DON stated that, because there was no COC documented for that date, the facility could not say that the MD or family were notified of the change in condition related to the alleged abuse, contrary to the facility’s policy requiring prompt notification and documentation of significant changes in condition.