Health inspection·October 1, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an accurate comprehensive person-centered care plan for one of three sampled residents (Resident 1), when Resident 1's exhibited behaviors were not monitored or documented. This failure had the potential to result in Resident 1 not receiving interventions necessary to maintain mental and psychosocial well-being. Findings: During a review of Resident 1's admission Face Sheet Record (face sheet), dated 10/13/2023, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (mood disorder causing persistently low or depressed mood and a loss of interest in activities), Panic Disorder (disorder with unexpected and repeated episodes of intense fear), and Post-Traumatic Stress Disorder (disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a concurrent observation and interview on 9/30/2024 at 10:45 a.m. with Resident 1, Resident 1 was observed in bed with a manual wheelchair at his bedside. Resident 1 stated that he was in the process of obtaining a power motorized wheelchair (wheelchair that is propelled by and electric motor), for easier mobility around the facility and its grounds. Resident 1 stated there was a meeting with his Interdisciplinary Team (IDT-team of professional and direct care staff that have primary responsibility for the development of a plan of care and treatment) on 7/22/2024, which the resident believed was to discuss obtaining the power motorized wheelchair, but instead, the team discussed Resident 1's aggressive behavior towards staff. During an interview on 9/30/24 4:45 p.m. with Director of Physical Therapy (DPT) 1, DPT 1 stated Resident 1 had a history of harassing behavior and was verbally aggressive toward her for the past two years which caused her to fear for her safety. DPT 1 stated Resident 1 approached her while she was alone in her office 4-5 times over the past two years yelling at her and calling her names. DPT 1 stated she did not document Resident 1's behaviors in the medical record and did not notify the IDT. DPT 1 stated she notified the psychiatrist of the resident's behaviors in July 2024 which prompted an IDT meeting. During an interview on 9/30/2024 at 4:30 p.m. with Social Services Director (SSD) 1, SSD 1 stated Resident 1 had a history of having verbally aggressive behaviors but has not had any episodes since Resident 1's readmission on [DATE]. SSD 1 was not aware of any behavior issues. SSD 1 further stated Page 1 of 2 555795 555795 10/01/2024 Veterans Home of California - Chula Vista 700 East Naples Court Chula Vista, CA 91911

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was not aware Resident 1 was verbally aggressive toward DPT 1 until the IDT meeting on 7/22/2024. SSD 1 stated the Social Services Department should be the first point of contact when behavior issues occured so that the IDT could develop a plan to address the resident's mental health needs. During an interview on 10/1/2024 at 9 a.m. with Supervising Registered Nurse (SRN) 1, SRN 1 stated behavior monitoring should be documented as indicated in Resident 1's care plan and nursing staff should document any behaviors noticed on their shift. SRN 1 stated other departments should notify nursing staff when a resident exhibits aggressive behavior so that the behaviors could be documented, and the resident could be monitored. SRN 1 stated she was not aware of Resident 1's aggressive behavior toward DPT 1 until a few days before Resident 1's IDT meeting on 7/22/2024. During an interview on 10/1/2024 at 9:35 a.m. with Medical Doctor (MD) 1, MD 1 stated the IDT depended on the documentation in the medical record for an accurate assessment of the resident. MD 1 stated Resident 1's exhibited pattern of behavior were traits of Resident 1's diagnoses and should have been documented in the medical record for the treatment team to effectively address the resident's mental health needs. During a review of Resident 1's care plan (CP) titled, PSYCO16A: CP#6A . Alteration in Mood/Behavior ., dated 10/7/2023 and updated 9/23/2024, the CP indicated interventions included, Monitor and Record Episodes of Targeted behaviors Every Shift on Monthly Drug Summary Sheet. During a review of the facility's policy and procedure (P&P) titled, Care Planning, updated 8/12/2024, the P&P indicated, . identify care needs based on an initial written and continuing assessment of the residents needs with input, as necessary, from health professionals involved in the care of the resident. 555795 Page 2 of 2