Inaccurate Behavior Monitoring Documentation for Dementia Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not accurately documenting behavior monitoring for a resident with vascular dementia and depression. The resident was assessed as confused and dependent on staff for care. Multiple observations over several days showed the resident was often calm, asleep, or pleasantly conversive, with no signs of agitation or aggression. However, the behavior monitoring documentation by nursing staff indicated continuous behaviors of agitation and aggression on several days and shifts, which was inconsistent with direct observations and staff interviews. Interviews with CNAs, an RN, and Life Enrichment staff confirmed that the resident had not exhibited aggressive or agitated behaviors recently, and was often calm or asleep during their shifts. The Director of Nursing Services stated that it was their expectation that behavior monitoring would be documented accurately. The discrepancy between the documented behaviors and actual observations/interviews demonstrates a failure to maintain accurate records in accordance with professional standards.