Failure to Document Behavioral Symptoms for Resident on Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to document and monitor the behaviors of a resident with multiple mental health diagnoses, as required by the care plan and physician orders. The resident was admitted with bipolar disorder, anxiety disorder, and dementia, and had physician orders for buspirone for anxiety, olanzapine for dementia, and venlafaxine for depression. The care plan and orders required behavior monitoring every shift for anti-psychotic, anti-anxiety, and anti-depression medications, using specific behavior codes and documentation of side effects and effectiveness. Review of the MARs from October 2025 to January 2026 showed only sporadic entries of behavior code “6. Noisy” on a few dates, despite standing orders for Q-shift behavior monitoring. Interviews with nursing staff revealed that the resident had frequent nighttime and daytime yelling and hollering episodes that were known and ongoing since admission. Night shift LPNs and CNAs reported that the resident regularly yelled out at night because he did not like to be alone, sometimes after bad dreams, and that this behavior occurred often. Staff described going into the room, asking the resident to stop yelling because others were sleeping, and attempting to meet his requests, but the yelling would resume. One LPN stated she had written a note in July 2025 about the behavior but otherwise the behaviors were typically recorded only on nurses’ report sheets used for shift-to-shift communication, which were not part of the clinical record. The DON, administrator, and corporate nurse confirmed that the nurses were not documenting the resident’s behaviors on the MARs as required and that the nurses’ report sheets were not official documentation. The DON stated she was unaware of the resident’s nighttime outbursts prior to a July 2025 note and that their process for new behaviors was to contact psychiatric services. Review of monthly psychiatric service notes showed the psychiatric provider documented the resident’s sleep as “fair” and relied on 24-hour nursing reports generated from MARs and progress notes. Because the resident’s frequent yelling and outbursts were not documented in the official record, these behaviors were not reflected in the reports used by the psychiatric provider, and the resident did not receive services based on accurate behavior monitoring as required by his care plan and orders.
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