F0684

D

Failure to Initiate Change of Condition Evaluation and 72‑Hour Monitoring After Alleged Abuse

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to create a Change of Condition (COC) evaluation and to initiate 72‑hour monitoring following an alleged physical abuse incident involving a resident. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, and gait and mobility abnormalities, and had been assessed as a high fall risk with significant dependence on staff for activities of daily living. The resident’s MDS indicated she rarely understood and was rarely understood, and her physician’s H&P documented that she did not have capacity to understand and make decisions.

On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA assigned to the resident to check on her. The CNA reported back that the resident was okay and that she always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. When the LVN entered the room, the LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf. The LVN untied the scarf and assessed the resident, noting no visible injury at that time. The DON and RMN later reviewed a photograph of the resident’s wrists tied with a scarf and both described the wrists as bound in such a way that the resident could not pull her arms apart, and the DON characterized this as physical abuse and use of a physical restraint.

Despite this alleged abuse incident, there was no COC evaluation initiated on the date the resident was found with her wrists tied. The RMN confirmed that alleged abuse is considered a change of condition and that a COC form should have been completed on that date to communicate with all staff, the MD, IDT, and family. The RMN and DON both stated there was no COC for the date of the allegation, and the RMN acknowledged that the RN supervisor should have started the COC at that time. The facility’s policy on Change of Condition Notification requires prompt notification of the physician, resident, and representative for significant changes in physical, cognitive, behavioral, or functional status, and requires licensed nurses to document the incident, physician notification, family notification, care plan updates, and to document each shift for at least 72 hours. In this case, the 72‑hour monitoring and COC documentation were not initiated until two days later, and the RMN stated there was no documentation that the MD was notified on the date of the incident, meaning the required timely COC evaluation and 72‑hour monitoring following the alleged abuse did not occur as required by policy.

The RMN further explained that the COC form is used to identify the change in condition and to initiate 72‑hour monitoring, which includes checking the resident’s psychosocial well‑being, assessing for new skin issues such as bruising from restraints, and monitoring the resident’s overall status. However, the COC completed later focused on restlessness and possible infection, not specifically on the abuse incident that occurred earlier. The Health Status Note indicating monitoring status post abuse incident and the initiation of 72‑hour monitoring were dated two days after the alleged abuse, confirming a delay in both recognition and documentation of the change in condition related to the abuse. The facility’s own leadership acknowledged that, because there was no COC documented for the date of the allegation, they could not confirm that the MD or family were notified of the change in condition at the time it occurred.