Inadequate Staff Competency in Behavioral Health Documentation
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to meet the behavioral health needs of its residents, as evidenced by the case of one resident. This resident, who was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and depression, reported increased anxiety over several weeks. Despite the resident's reports, the nurse practitioner did not adjust the anti-anxiety medication due to a lack of documented symptoms in the nursing records. The facility's policy requires behavioral health services to be provided in accordance with comprehensive assessments and care plans, but the documentation did not reflect the resident's increased anxiety symptoms. The resident's clinical records showed that anxiety behavior tracking was inconsistently documented in the Medication Administration Record (MAR) and progress notes. For the month of March, the majority of shifts lacked documentation of anxiety behavior tracking, with only 11 incidences recorded in the MAR and 5 additional shifts noted in progress notes. A psychiatry note indicated the resident's anxiety was affecting sleep, yet staff documentation did not reflect these symptoms. An interview with the Director of Nursing confirmed the lack of documentation per physician orders, highlighting the facility's failure to employ staff with the necessary competencies to ensure resident safety and well-being.