Failure to Timely Address and Document New Behavioral Changes
Penalty
Summary
The facility failed to timely address a newly identified behavior in a resident with a history of anxiety and heart failure. The resident, who was cognitively intact and had documented episodes of depression, exhibited inappropriate behaviors such as refusal of care, confabulation, and verbal aggression on multiple days, as recorded in the behavior monitoring record. Despite these behaviors, interventions were largely ineffective, and there was no documentation of additional behaviors in the progress notes for over a month. Staff interviews revealed that the resident had recently displayed physical aggression by banging a walker against the wall, but this incident was not reported or documented by staff who witnessed it, as they assumed others were aware. Further interviews indicated that key staff, including the Social Services Director and the Director of Nursing Services, were unaware of the resident's physical aggression and expected such incidents to be documented to facilitate timely intervention. The Social Services Director acknowledged the need for a new behavioral assessment and consideration of additional behavioral services due to the change in the resident's behavior. The facility assessment also indicated insufficient behavioral health staffing, which may have contributed to the lack of timely response and documentation regarding the resident's behavioral changes.