Failure to Monitor and Document Behavioral Health Interventions
Penalty
Summary
Nursing staff failed to adequately monitor and document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident, who was prescribed multiple antidepressant medications for depression, did not have a physician order for monitoring signs and symptoms of depression or medication side effects, despite a care plan intervention requiring such monitoring. The lack of monitoring was confirmed by the Director of Nursing, who acknowledged that appropriate orders and monitoring were not in place prior to the surveyor's inquiry. Two additional residents with orders and care plans for behavioral monitoring related to psychiatric or behavioral issues did not have documentation of behavior monitoring as required. For one resident, there was an order to monitor target behaviors every shift, but no documentation was found for several months until after the surveyor raised the issue. Another resident had a physician order and care plan for monitoring specific behaviors associated with schizophrenia, but the required monitoring was not documented on the Medication Administration Record. These failures were confirmed by facility administrative staff during the survey.