Failure to Accurately Document Behavior Monitoring
Penalty
Summary
The facility failed to accurately document the completion of behavior monitoring for one resident who was reviewed for unnecessary medications. During a 90-day review period, it was found that behavior monitoring records were missing for three specific day shifts. Although the Director of Nursing confirmed the absence of documentation in the behavior monitoring record for those dates, she was able to provide CNA documentation indicating that behavior monitoring had taken place. The expectation was that nurses would complete the required documentation appropriately, but this was not done for the identified dates. This deficiency was identified during a survey that reviewed five residents for unnecessary medications, with a facility census of 65 at the time.