Failure to Document Resident Behaviors in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's inappropriate sexual behaviors were documented in the electronic medical record in accordance with accepted professional standards. For one resident with diagnoses including dementia, cognitive communication deficit, and muscle weakness, multiple incidents of sexually inappropriate behavior toward staff were recorded on handwritten 'Behavior Sheets.' These incidents included grabbing, inappropriate touching, and attempts to kiss staff members during care. The handwritten notes described the behaviors, staff interventions, and outcomes, but were not included in the resident's official electronic medical record. The Executive Director confirmed during interview that such behaviors should be documented in the electronic medical record's progress notes. The facility's policy also required documentation of behavioral incidents in the clinical record, including details such as time, causative factors, actual behavior, interventions, and outcomes. However, the handwritten notes were only provided after the survey began and were not part of the resident's official medical record, resulting in an incomplete and inaccurate clinical record for the resident.