Incomplete and Inaccurate Behavior Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurate, specifically for a resident being monitored for mood and behaviors. Physician orders required detailed documentation of behavior monitoring, including specific codes for types of behaviors, interventions used, outcomes, and any side effects. However, the Treatment Administration Record for the resident only contained check marks and staff initials, lacking the required detailed information. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the documentation did not include the necessary coding or details about the resident's behaviors, as required by the physician's order and facility policy. Further review of the resident's progress notes revealed inconsistencies in documentation regarding medication refusal and behavioral observations. While the APRN noted that the resident was refusing medications, the progress notes also stated that no behaviors were observed during a shift. The facility's policies require accurate and complete documentation to reflect the resident's experiences and to monitor behaviors effectively. The deficiency was identified due to the lack of detailed and accurate documentation in the resident's medical record, contrary to both physician orders and facility policy.