F0689

D

Failure to Manage Escalating Aggression and Delusions Resulting in Resident-to-Resident Assault

Rosemead, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement effective interventions and supervision for a resident with escalating verbal aggression and delusions, which resulted in that resident physically striking another resident. Resident 54 was admitted with schizophrenia, anxiety disorder, bipolar disorder, depression, psychotic disorder, and documented delusions, and had a conservatorship order stating she was gravely disabled and unable to provide for basic personal needs. Her care plan, initiated on 2/13/2026, identified potential for verbal and physical aggression related to ineffective coping skills, mental and emotional illness, and poor impulse control, with goals that she not harm herself or others. Interventions listed included analyzing triggers and circumstances, assessing coping skills and support systems, anticipating and assessing needs, and identifying and addressing contributing sensory deficits.

In the days leading up to the incident, multiple records documented a clear increase in Resident 54’s verbal aggression and delusional thinking. A Change of Condition (CoC) evaluation on 3/9/2026 at 5:30 PM recorded that she was verbally aggressive, cursing, yelling, and shouting at staff and other residents, with staff attempting redirection and close monitoring for safety. Nursing progress notes from 3/9/2026 through 3/12/2026 described multiple episodes of increased verbal aggression toward staff and residents, with staff sometimes able to redirect her and sometimes unable to do so. The Medication Administration Record for March 2026 documented 13–16 episodes of increased delusions and aggression toward staff and residents between 3/9/2026 and 3/15/2026. Staff interviews confirmed that for approximately one to three weeks before the physical incident, Resident 54 had increased verbal aggression, increased delusions, and periods of withdrawal and staying in bed, and that she sometimes did not comply with redirection.

Despite these documented changes, the facility did not implement additional or modified interventions beyond redirection and monitoring, nor did it effectively escalate concerns for timely psychiatric evaluation. The Assistant Director of Nursing (ADON) spoke with the psychiatrist (Physician 5) on 3/10/2026 about possible medication adjustments, and the psychiatrist stated he would conduct an in‑person evaluation before making changes, but he did not come to the facility between 3/10/2026 and 3/13/2026. A nursing note on 3/13/2026 documented that the ADON attempted to call the psychiatrist and was unable to reach him, and the ADON acknowledged he did not notify the psychiatrist’s nurse practitioner or the psychiatric medical director, even though existing interventions were not effective and the resident had the potential to harm others. On 3/16/2026 at 7:00 AM, a CoC record documented that a CNA witnessed Resident 54 elbow Resident 25 in the right cheek while Resident 25 was quietly reading her Bible in her wheelchair in an alcove. Statements from staff and residents indicated that Resident 54 approached Resident 25, used a racial slur, and then struck her with an elbow to the right side of the face. The facility’s Resident Safety policy required evaluation when there is a change of condition to identify circumstances that pose a risk for safety and well‑being, but the documented escalation in aggression and delusions was not met with effective interventions to prevent the physical assault.