Failure to Document Resident Altercation and Related Behaviors
Penalty
Summary
The facility failed to ensure accurate documentation of an incident involving a verbal altercation and related behaviors between two residents. One resident, who had a history of monoplegia following a stroke, was moved to a new room after a previous altercation. Upon being placed with a new roommate, the resident was observed by staff and the new roommate to be agitated, bumping her wheelchair into objects, and making threatening statements over the phone. The new roommate became emotionally distressed, activated her call light, and was subsequently moved to another room by staff. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed that the incident was not documented in the medical record of the resident who made the threatening statements. The facility's policy requires that all changes in a resident's condition, as well as events, incidents, or accidents, be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no evidence of documentation in the medical record regarding the incident involving the verbal altercation and the resident's behaviors. Record reviews showed that while some documentation existed in the new roommate's records, including an SBAR summary and an IDT note describing the emotional distress and the events that occurred, there was a lack of corresponding documentation in the record of the resident who was the source of the altercation. This omission was confirmed by the DON during a review of the progress notes, indicating a failure to comply with the facility's documentation policy.