Failure to Ensure Staff Competency in Identifying and Documenting Mood, Behaviors, and Side Effects
Penalty
Summary
The facility failed to ensure that nursing staff, including nurses and nurse aides, were properly educated and competent in identifying and documenting residents' mood, behaviors, and side effects. During a record review with the DON, it was revealed that concerns had been identified regarding incomplete or inaccurate documentation of these areas. Although agendas from several staff education sessions listed topics such as notifying nurses of behaviors and documenting behaviors and side effects, no proof of actual education or specific content covered was provided. The DON confirmed that staff were not consistently identifying abnormal behaviors, and the documentation reviewed did not reflect specific mood, behavior, or side effect information.