Failure to Notify Provider of Resident's Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that staff notified the physician or psychiatric provider when a resident with dementia exhibited repeated violent and aggressive behaviors. The resident, who had a history of aggression towards both staff and other residents, was admitted with a diagnosis of dementia and was prescribed multiple psychotropic medications. Despite multiple documented incidents of the resident hitting, attempting to bite, and making verbal threats towards staff and other residents, there was no evidence in the medical record that these behaviors were reported to the primary care or psychiatric provider on the days they occurred. The resident was also sent to the hospital for aggressive behaviors, but upon return, there was no documentation of changes in medication or increased supervision, nor was there evidence that the provider was informed of the ongoing aggression. Nursing notes detailed several episodes where the resident required 1:1 supervision, attempted to harm staff, and made threatening statements, yet there was no documentation of provider notification or orders for increased supervision. Interviews with nursing staff and the DON confirmed that such incidents should have been reported to the provider, but the medical record lacked evidence of timely communication. The deficiency was identified during a survey review of abuse prevention and reporting practices, with cross-reference to F 600.