Failure to Document Resident Behaviors as Required
Penalty
Summary
The facility failed to document a resident's behaviors as required for one of three residents reviewed. Certified Nurse Aides (CNAs) observed that the resident had increased behavioral issues, specifically kicking during care, over a period of two to three weeks. The CNAs reported these behaviors to the nurses, as they did not have access to document behaviors themselves. Licensed Practical Nurses (LPNs) confirmed that such behaviors should be documented in the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) or in a progress note. However, a review of the resident's clinical record and progress notes for the relevant period showed no documentation of these behaviors, despite a physician's order requiring staff to monitor the resident's behavior every shift. The resident in question was noted to be severely cognitively impaired and had diagnoses including hypertension, non-Alzheimer's dementia, and malnutrition. Facility policies provided by the Assistant Director of Nursing (ADON) emphasized the critical importance of thorough documentation of resident behaviors, including details such as time, causative factors, actual behavior, interventions, and outcomes. Despite these policies and the physician's order, the required documentation was not present in the resident's record for the specified dates.