Failure to Accurately Document Behavioral Monitoring and Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain accurate and complete medical records related to behavioral monitoring for a resident with documented psychiatric conditions. The resident had a psychiatric evaluation indicating depression and anxiety, with a treatment plan calling for continuation of current treatment and routine monitoring of mood and behavior. A subsequent psychiatric progress note documented that the resident presented as frustrated, irritable, angry, and verbally expressed a desire to leave the facility, along with complaints of sleep difficulty and fatigue. During the survey, the resident was again observed to be irritable, easily agitated, and expressing a desire to leave immediately. Physician orders directed staff to perform behavior monitoring every shift and to document the frequency of behavioral episodes, the interventions used, and the outcomes, using specified intervention codes. Review of the January Medication Administration Record (MAR) showed that on two shifts, staff had indicated that behaviors were present, but there was no further description of the behaviors, no documentation of the frequency of episodes, and no record of any interventions or outcomes. When questioned, the DON stated she was unsure what the MAR documentation indicated and later confirmed that the documentation did not clarify staff findings. The DON agreed that when behaviors are identified, there should be additional description and documentation of what was observed and what treatment was provided, and acknowledged that the documentation was not accurately completed.
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