Failure to Document and Report Crisis Prevention Intervention Incident
Penalty
Summary
The facility failed to follow its behavior management policy and document an incident involving the use of crisis prevention intervention (CPI) techniques on a resident. On the morning in question, a staff member (activity aide/CNA) physically intervened with a resident by grabbing both wrists, taking the resident to the floor, and holding them in that position. This action was not reported to the nurses on duty, the acting administrator, or the director of nursing at the time. Multiple staff interviews confirmed that the incident was not communicated through proper channels, and the required documentation in the nursing notes was not completed. The resident did not receive an assessment for injuries following the incident, and the event was not reviewed as per facility policy. The facility's behavior management policy requires staff to use the least restrictive interventions, document resident behavior and symptoms, perform an assessment, and notify family or physician after such incidents. The abuse policy also mandates documentation and internal investigation of all incidents, whether or not abuse is suspected. In this case, the staff member's actions were not consistent with CPI training, and the incident was not documented or reported according to policy, resulting in a failure to safeguard resident-identifiable information and maintain accurate medical records.