Failure to Timely Monitor and Document After Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident who experienced abuse was properly monitored for any resulting problems. Specifically, after a Certified Nursing Assistant (CNA) was rough with the resident and threw personal care items at him, staff did not complete required change in condition charting immediately following the incident. Additionally, alert charting, which is meant to provide ongoing documentation and monitoring for 72 hours after such incidents, was not initiated until two days after the event. These actions were not in accordance with the facility's own policies, which require documentation of significant changes in condition and monitoring after abuse or unusual occurrences. The resident involved had a diagnosis of dementia, which affects memory and decision-making abilities. Review of the resident's progress notes confirmed the absence of timely change in condition documentation and a delay in starting alert charting. The Assistant Director of Nursing verified that these documentation requirements were not met as per policy following the incident of abuse.