Failure to Implement and Document Required Alert Charting After Incidents
Penalty
Summary
The facility failed to implement care plan interventions for two residents following incidents that required monitoring for potential psychosocial effects. One resident, admitted with schizophrenia, reported being hit on the head and claimed to have lumps and bumps. The care plan for this resident included alert charting for 72 hours to monitor for possible psychosocial effects of the reported incident. However, documentation confirmed that alert charting was not completed by licensed nurses on two subsequent days as required. Another resident was involved in a verbal altercation with a peer, after which staff were instructed to monitor both individuals for behavioral changes. The care plan for this resident also required alert charting for 72 hours to assess for any adverse psychosocial effects. Record review and staff interviews confirmed that no alert charting was completed for this resident during the specified period. Facility policy mandates documentation of such incidents and subsequent care every shift for at least 72 hours, which was not followed in these cases.