Inaccurate Behavioral Documentation for Resident With Psychiatric and Cognitive Disorders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia. The resident’s interdisciplinary team note documented that the resident struck another resident in the face in the dining room without apparent provocation. A nurse’s note later documented that the same resident approached another resident in the hallway, yelled, grabbed the other resident’s arm, and was then struck and knocked to the floor. A psychiatric progress note also stated that staff reported the resident had been anxious, aggressive at times, and continued to have mood swings and aggression. Despite these documented incidents and provider observations, the resident’s December medication administration record (MAR) behavior monitoring for agitation, irritability, and hypervigilance was incomplete and inaccurate. One day’s behavior monitoring entry was left blank, and on the days when the resident was involved in physical altercations, the MAR documented zero episodes of agitation or irritability. During interviews, a licensed nurse and the ADON acknowledged that the MAR entries were incorrect and that nursing notes did not reflect the anxiety, aggression, or mood swings described in the psychiatric note. This resulted in a medical record that did not accurately represent the resident’s behavioral condition, contrary to the facility’s policy requiring objective, complete, and accurate documentation of changes in a resident’s condition.
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