Failure to Monitor and Document Resident Status After Abuse Incidents
Penalty
Summary
The facility failed to ensure that residents involved in resident-to-resident abuse incidents were properly monitored for injuries, mood, and behaviors as required by facility policy and care plans. For four residents with varying degrees of cognitive impairment and psychiatric diagnoses, documentation and monitoring were not consistently completed following altercations. Specifically, after incidents where residents were struck or involved in altercations, there was a lack of documented assessments regarding their mood, behavior, and physical condition on multiple shifts over several days. For example, one resident with vascular dementia and a history of traumatic brain injury was involved in an altercation and subsequently had interventions listed in the care plan, including RN assessment and monitoring for mental distress. However, there were no physician orders or MAR entries for mood or behavior monitoring, and nurses' notes lacked documentation of these assessments on several shifts following the incident. Similar deficiencies were observed for other residents involved in altercations, including those with severe cognitive impairment and mood disorders, where care plans called for monitoring and support, but documentation and orders for such monitoring were absent. Interviews with facility leadership confirmed that nursing staff were expected to monitor and document mood, behavior, and skin condition for all residents involved in such incidents every shift for 72 hours. Despite this expectation, the Director of Nursing was unaware that monitoring and documentation were not completed consistently and acknowledged that education and audits regarding this requirement were lacking. Review of facility policy also indicated that staff should observe, intervene, and monitor residents following abuse incidents, but these actions were not consistently documented or carried out.