Failure to Assess and Document Behavioral Health Needs
Penalty
Summary
The facility failed to assess or document the behaviors of a resident diagnosed with dementia with behavioral disturbance. Despite the resident exhibiting worsening agitation, wandering, and behaviors such as entering other residents' rooms and touching their belongings, there was no documentation or behavior monitoring order in the medical record. The resident was prescribed medications for behavioral health needs upon admission, but the facility did not implement or record any behavior monitoring as required. Interviews with facility staff revealed that information about the resident's behavioral issues was communicated verbally rather than documented. The Psychiatric Nurse Practitioner confirmed awareness of the resident's aggressive behaviors through verbal reports only, and the DON acknowledged that behavior monitoring should have been documented in the Treatment Administration Record. Upon review, the DON verified the absence of any assessment or documentation of the resident's behaviors in the medical record.