Failure to Document Resident Behaviors and Interventions in Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple diagnoses, including COPD, congestive heart failure, and a history of repeated falls. A physician's order required documentation of the resident's inappropriate sexual comments towards staff on the Treatment Administration Record (TAR), including the number of episodes, interventions, and outcomes. The care plan also indicated that behavior tracking was in place for these behaviors. However, review of the resident's TAR and progress notes over several months revealed no documentation of any sexually inappropriate comments or behaviors, despite staff and administrative acknowledgment that such incidents occurred and resulted in the resident not receiving showers on specific dates. The Director of Nursing confirmed that these behaviors should have been documented but were not.