Santa Monica Health Care Center

During a review of Resident 2's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 12/13/2025 indicated, Resident 2 need to have a sitter but allowed to go out of facility.

During an interview on 12/24/2025 at 10:57 AM with Certified Nurse's Aide (CNA) 1, CNA 1 stated Resident 2 gets aggressive, agitated, frustrated when [Resident 2] doesn't get [Resident 2's] way. [Resident 2] is not calm. CNA 1 stated the potential harm that may come to Resident 2 while out on pass (OOP - a patient has temporary, authorized leave from the facility for a short period [hours to a day or two] to go home or elsewhere, often for family visits or personal needs, with arrangements for their return, requiring physician and nursing approval and documentation) may cause physical contact with others like argue with another civilian.might argue too much and start fighting but only when [Resident 2] doesn't get [Resident 2's] way.

During an interview on 12/24/2025 at 11:12 AM with a licensed vocational nurse (LVN) 1, LVN 1 stated [Resident 2] doesn't get along with roommates.[Resident 2] causes problems so roommates will be moved to another room. LVN 1 stated Resident 2 needed to be on a 1:1 with a sitter because [Resident 2] might hurt a staff or other residents here.unpredictable behavior. LVN 1 stated the potential harm that may come to Resident 2 while out on pass without a staff member was physical harm - fall, break arm or leg, and Resident 2 may come in contact with someone where [Resident 2] does not agree with and get into an argument.

During an interview on 12/24/2025 at 12:05 PM with a registered nurse supervisor (RNS), RNS stated Resident 2 does not interact with other residents, just stays in the room; yells at staff; does not want anybody near [Resident 2]. RNS also stated Resident 2 does not listen to reasons.

When asked why Resident 2 needed a 1:1 with a sitter, RNS stated to protect the other patients and that Resident 2 is always angry at something. RNS stated [Resident 2] needs a sitter to prevent [Resident 2] from getting angry at people like residents and staff, and to prevent the same incident - physical altercations - from happening again. RNS stated the potential harm that may happen to Resident 2 when Resident 2 is out on pass is that [Resident 2] may provoke somebody and will start a fight, trip and fall, and get into altercation with another person while out of the facility.

During an interview on 12/24/2025 at 2:10 PM with the Director of Nursing (DON), the DON stated Resident 2's physician ordered a 1:1 with a sitter for safety started on 12/10/2025, all shifts due to [Resident 2's] aggressive behavior. DON also stated that Resident 2 does not require to have a 1:1 with a sitter when OOP we only do for here; [Resident 2] is alert.can go to the bus.our responsibility is for [Resident 2] inside the facility and not be aggressive to other residents; when [Resident 2] is outside, [Resident 2] goes alone.[Resident 2] is responsible for herself when [Resident 2] is out there.

During a review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Safety Supervision of Residents undated, indicated the facility's individualized, resident-centered approached to safety addresses safety and accident hazards for individual residents.

The P&P also indicated that resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is based on the assessed needs and identified hazards in the environment.

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