Inaccurate Behavior Monitoring and Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation for a resident with multiple psychiatric diagnoses, including dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and anxiety disorder. The resident’s care plans, initiated and updated in December and January, identified verbal aggression, racial and derogatory remarks, screaming at others, and accusations that staff were hurting or stealing from her. Interventions included administering medications as ordered and monitoring and documenting behaviors, including the time and day of occurrences, as well as monitoring for side effects and effectiveness of psychotropic medications. Despite these documented behavior problems and care plan directives, the resident’s January MAR instructed staff on all three shifts to monitor episodes of mood swings manifested by aggressive behavior toward others and to tally them with hashmarks every shift, yet the MAR showed no mood swing or aggressive behavior episodes from early January through late January. This lack of documentation conflicted with multiple staff interviews and other records. The DON and CNA reported that the resident was verbally aggressive toward staff and residents, screamed at CNAs and nurses, especially during medication administration, and exhibited aggressive behavior about three times a week, sometimes daily since December. Change of Condition forms and nursing notes showed transfers to the hospital due to aggressive behavior in December and January, further contradicting the absence of behavior tallies on the MAR. Additionally, the Physician Discharge Summary inaccurately documented the reason for the resident’s discharge as attempts to elope, even though the Elopement Risk Assessment rated the resident as low risk for elopement and a review of Change of Condition reports and nursing notes from late January to early February revealed no elopement attempts. The DON confirmed that the true reason for discharge was the resident’s aggressive behavior, not elopement, and acknowledged that the discharge summary was inaccurate. The facility’s own nursing documentation policy required concise, clear, pertinent, and accurate documentation, which was not met in the behavior monitoring on the MAR or in the stated reason for discharge on the Physician Discharge Summary.
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