Failure to Monitor and Document Psychosocial Well-being After Alleged Incident
Penalty
Summary
Licensed nurses and social services staff failed to monitor and document the psychological and psychosocial well-being of a resident following the resident's report of being inappropriately touched by transportation company personnel. The resident, who had diagnoses including major depressive disorder and anxiety disorder, reported the incident to the Social Services Director (SSD), but there was no documented evidence in the resident's progress notes that any follow-up monitoring occurred after the allegation. The SSD confirmed that she did not document any follow-up visits and acknowledged that if monitoring was not documented, it was considered not to have happened. The Director of Nursing (DON) also confirmed that neither licensed nurses nor social services documented any monitoring of the resident's psychological and psychosocial health after the incident was reported. The facility's policy required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, but this was not followed in this case. The lack of documentation and monitoring occurred despite the resident's intact cognition and known mental health diagnoses.