Failure to Monitor and Document Aggressive Behavior in Resident with Psychiatric Diagnosis
Penalty
Summary
Facility staff failed to monitor a resident with a known history of verbal and physical aggression, as ordered by the physician. The resident, diagnosed with schizoaffective disorder and exhibiting cognitive impairments, had a physician order in place requiring staff to monitor and document episodes of verbal and physical aggression. Despite this order, review of the behavior monitoring flowsheet revealed that staff did not document or monitor the resident's aggressive behaviors. The Director of Nursing confirmed that the monitoring was not completed as required, and the purpose of the monitoring was to identify escalating behaviors and prevent further incidents. This deficiency was highlighted when the resident struck another resident in the face without provocation and expressed a desire to hit someone again. Interviews with staff indicated that the resident had a history of aggressive behavior and was considered a safety risk to others. Facility policies required monitoring of residents at risk for unsafe behavior, but these procedures were not followed, resulting in a lack of documentation and monitoring for the resident's aggression.