Failure to Document Resident Interactions and Behavioral Events
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents with behavioral and mental health diagnoses. Specifically, the clinical records for two residents, both with histories of dementia, mood disorders, anxiety, depression, and bipolar disorder, did not reflect significant events and interactions that occurred between them. Although social services and staff were aware of a close relationship between the two residents, including kissing and being alone together in private areas, these interactions were not documented in the residents' progress notes over the past three months. Staff interviews confirmed that such events occurred, and that staff intervened and reported the incidents to nursing management, but there was no corresponding documentation in the clinical records. Additionally, the facility's policy on behavior management and monitoring was not followed as required, as evidenced by the lack of documentation regarding the residents' interactions and the behavioral concerns that prompted room changes and increased monitoring. The absence of accurate and complete records for these residents, despite their complex behavioral histories and the facility's awareness of their interactions, constitutes a failure to maintain medical records in accordance with accepted professional standards.