Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of two residents, leading to a deficiency in compliance with the requirement that each resident's drug regimen must be free from unnecessary drugs. Resident #7, who was admitted with severe cognitive impairment, had a physician's order to monitor specific behaviors and document interventions. However, there were instances where behaviors were observed, but no intervention codes or detailed documentation were recorded in the nursing progress notes or Medication Administration Record (MAR). Similarly, Resident #23, also with severe cognitive impairment, had a physician's order to monitor behaviors and document interventions using specific codes. The MAR showed check marks instead of the required 'Yes' or 'No' to indicate the presence of symptoms, and there was a lack of documentation in the progress notes regarding the resident's behavior and the interventions implemented. This lack of documentation and adherence to physician's orders was acknowledged by the Director of Nursing during a review of the residents' records. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, revealed that while there was an understanding of the need to monitor and document behaviors, the actual practice did not align with the facility's policy or the physician's orders. The Director of Nursing confirmed the deficiency in documentation, which contributed to the facility's failure to meet the regulatory requirement of ensuring residents' drug regimens are free from unnecessary drugs.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On __, residents #7 and #23 clinical charts were reviewed. Licensed nurses were re-educated on following physicians orders for monitoring of behavior and documentation of intervention codes. Identification of other residents potentially affected: Quality review audit of current residents at risk for behavioral monitoring and interventions was completed. No other residents were affected. Measures: On re-education initiated to licensed nurses by the Director of Nursing on following physician orders for monitoring of behavior and documentation of intervention codes. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure physicians orders are being followed for behavior monitoring and documentation to ensure the appropriate treatment and or behavioral interventions are being used to meet the needs of the residents. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.