Failure to Provide and Document Ordered 15-Minute Behavioral Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required behavioral health monitoring for a resident with significant cognitive and psychiatric conditions. A quarterly MDS assessment dated 11/21/2025 showed that Resident C was severely cognitively impaired, with diagnoses including bipolar disorder and non-Alzheimer’s dementia. A psychiatric progress note dated 01/27/2026 documented increased physical and verbal aggression toward peers and indicated the resident was on one-on-one staff monitoring. The psychiatric provider ordered 15-minute monitoring for 72 hours unless the resident was accepted by an inpatient facility. Resident Location Monitoring Forms showed one-on-one monitoring began on 01/26/2026 at 3:15 P.M. and was discontinued on 01/29/2026 at 6:00 A.M., but there was no indication of when the resident transitioned from one-on-one to 15-minute checks, nor which staff member documented the resident’s location. During interviews, the Social Services Director stated the same form was used for both one-on-one and 15-minute monitoring and acknowledged she could not determine when the change in monitoring level occurred, noting that staff initials should have been present next to every entry. The DON reported that the psychiatric NP changed the order from one-on-one to 15-minute monitoring on 01/27/2026 at 10:15 A.M., but due to already scheduled staffing, the resident remained on one-on-one monitoring until midnight that day. The DON further indicated the resident was taken off 15-minute monitoring on the morning of 01/29/2026 due to decreased behaviors and then restarted on one-on-one monitoring at 6:00 P.M. that evening when behaviors increased again. After reviewing the documentation, the DON stated the resident should have remained on 15-minute monitoring for the full 72 hours after the psychiatric visit. Facility policies on fifteen-minute monitoring and behavioral emergencies required additional supervision and continuous staff presence during behavioral episodes, with possible reduction to 15-minute checks, but the facility’s documentation and implementation did not reflect adherence to the ordered 72-hour 15-minute monitoring period.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.