LOS ANGELES, CA - State health inspectors documented multiple deficiencies at Sharon Care Center related to the care of a resident with serious mental health conditions, including failures to notify physicians of behavioral changes and inadequate care planning that ultimately resulted in a psychiatric emergency requiring hospitalization.
Failure to Report Escalating Behavioral Concerns
Health inspectors identified a critical lapse in communication protocols when facility staff failed to notify the attending physician about a significant behavioral incident involving a resident with schizophrenia, major depressive disorder, and moderate cognitive impairment.
On January 14, 2025, at 11:13 p.m., the resident became increasingly agitated over medication scheduling, telling staff, "I will pull your hair if you don't give me the medication." Documentation showed this verbal aggression was recorded as a change in condition, yet the physician was never informed of the incident. The facility's own Situation Background Assessment and Recommendation form explicitly noted that the physician had not been contacted.
This breakdown in communication violated fundamental protocols for managing residents with mental health conditions. When individuals with schizophrenia and depression exhibit new or escalating behavioral symptoms, immediate physician notification is essential. Changes in behavior can signal medication ineffectiveness, disease progression, or the onset of medical complications that require prompt intervention. Without physician involvement, treatment adjustments cannot be made, potentially allowing dangerous behaviors to escalate.
A second incident on March 3, 2025, revealed similar documentation failures. When the resident reported inappropriate comments from her roommate and became agitated, facility documentation dismissively characterized her concerns, stating the resident "create situation to be getting extra attention." No physician recommendations were documented in response to this behavioral change.
Inadequate Care Planning for Mental Health Needs
Inspectors found that facility staff failed to update the resident's care plan following documented behavioral incidents, despite clear evidence of escalating mental health symptoms. The resident's assessment indicated she experienced feelings of depression and hopelessness seven to 11 days within the rating period, yet her care plan was not revised after the January and February behavioral changes.
Particularly concerning was the lack of individualized interventions for the resident's antipsychotic medication quetiapine (Seroquel) and schizophrenia diagnosis. Comprehensive care planning for residents with schizophrenia requires specific interventions tailored to the individual's symptoms, triggers, and response patterns. Generic approaches are insufficient for managing complex psychiatric conditions.
Effective care planning for mental health conditions should include detailed behavioral monitoring protocols, environmental modifications to reduce triggers, strategies for de-escalation, and clear criteria for when to seek additional medical intervention. The care plan should be a living document that evolves as the resident's condition changes, incorporating lessons learned from each behavioral incident.
Crisis Intervention and Emergency Response
The consequences of these systemic failures became evident on March 6, 2025, when the resident attempted to harm herself using a hair bonnet during what staff documented as an episode of altered mental status and personality changes. The incident required intervention from multiple staff members, including licensed nurses, certified nursing assistants, activities staff, and the maintenance director.
Emergency responders were called, and the resident was placed on an involuntary psychiatric hold, a legal mechanism used when individuals are deemed a danger to themselves or others due to mental illness. She was transported by ambulance to a general acute care hospital for psychiatric evaluation and treatment.
This emergency hospitalization represented a failure of the facility's preventive care systems. The escalating pattern of behavioral changes documented over nearly two months—from verbal threats in January to self-harm attempts in March—demonstrated a clear trajectory that should have triggered more aggressive intervention much earlier.
Additional Issues Identified
Beyond the primary violations, inspectors documented related concerns about the facility's change-in-condition notification procedures. The facility's own policy, revised in December 2024, explicitly requires immediate physician notification for significant changes in a resident's mental or psychosocial status, deterioration in health, or clinical complications. Staff interviews confirmed awareness of this requirement, with the Director of Nursing acknowledging that physician notification is "important because they will give new orders or instructions on how to handle the behaviors presented."
The licensed vocational nurse interviewed during the inspection admitted there was no documented evidence the physician had been notified about the behavioral changes, acknowledging that physicians "must be informed about all changes in condition."
The violations raise questions about systemic issues in mental health care delivery at the facility, including staff training on psychiatric symptom recognition, the adequacy of behavioral health resources, and the effectiveness of quality assurance monitoring systems designed to catch such lapses before they result in resident harm.
For residents with serious mental illness, consistent monitoring, timely physician involvement, and individualized care planning are not optional components of care—they are essential safeguards that can prevent psychiatric crises and hospitalizations. The documented failures at Sharon Care Center demonstrate what can happen when these fundamental protections break down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sharon Care Center from 2025-03-12 including all violations, facility responses, and corrective action plans.
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