Failure to Document Behavioral Symptom Monitoring for Depression
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility staff failed to document the monitoring of behavioral symptoms for one resident who had an order for depression symptom monitoring during the month of April. Clinical record review showed that the required behavior monitoring documentation was missing. During an interview, the DON and surveyor reviewed the electronic health record and found that the responsibility for monitoring had been incorrectly assigned to ancillary staff instead of nursing, resulting in the monitoring task not appearing on the Medication Administration Record for nursing staff to document.