Failure to Document and Monitor Targeted Behaviors for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to document and monitor targeted behaviors for one resident with a history of schizophrenia, depression, visual and auditory hallucinations, uncontrollable crying, delusional thoughts, and agitation. The resident was identified as moderately cognitively impaired and had a care plan in place that required monitoring for symptoms such as irritability, agitation, tearfulness, and changes in mood, with documentation of any observed changes and updates to the care plan as needed. During an interview, the resident cried several times when discussing her living situation, a fall, and activities. Although a Licensed Practical Nurse was alerted to these crying episodes, there was no documentation of the incidents in the resident's progress notes. Staff interviews confirmed that such behaviors should have been documented, regardless of who witnessed them, and that documentation is necessary for tracking and intervening in behavioral issues.