Failure to Document Resident Refusals and Aggressive Behaviors
Penalty
Summary
The facility failed to accurately document the behaviors and refusals of care for a resident with a medical diagnosis of a left knee infection related to an internal prosthetic. The resident was alert and oriented upon admission. Multiple staff interviews revealed that the resident exhibited verbally aggressive behaviors, including cussing at staff, refusing care such as wound dressing changes and urinal emptying, and expressing intentions to leave the facility against medical advice. Staff described the resident as agitated, frustrated, and resistive to assistance, with specific incidents where the resident verbally abused staff and refused interventions. Despite these reported behaviors and refusals, a review of the resident's medical record showed no documentation of these events. The facility did not have a specific policy for documenting behaviors, but the expectation was that refusals of care would be recorded in the chart. The lack of documentation was confirmed during interviews with staff and the corporate nurse, indicating a failure to maintain accurate and complete medical records in accordance with accepted professional standards.