Failure to Document and Monitor Resident After Staff Altercation
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services in accordance with professional standards of practice for a resident with a history of cerebral infarction, mood disorder, and major depressive disorder with psychotic symptoms. After an altercation between the resident and a CNA, in which both parties admitted to physical contact, the resident's daughter contacted adult protective services and the police were involved. The resident was observed in bed with no visible injuries following the incident. Despite facility policy requiring increased supervision and documentation for at least 72 hours following such incidents, there was only one documented entry in the resident's clinical record during the required monitoring period. The DON confirmed that nursing staff should have documented the resident's status for 72 hours post-incident, but this was not done, with only a single entry recorded. This lack of documentation failed to ensure the resident's health, safety, and well-being were adequately monitored after the incident.