Failure to Accurately Document Resident Behaviors in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation of behaviors in the medical record of a resident with Alzheimer's disease, wandering, anxiety, type II diabetes, and depression. The resident, admitted on 10/07/22, had impaired cognition per a quarterly MDS assessment and exhibited continuous inattention and disorganized thinking, along with physical and verbal behaviors, wandering, behaviors directed toward others such as hitting or scratching, and rummaging. The resident’s care plan dated 01/22/26 identified behavior problems related to frequent wandering into other residents’ rooms and being combative with redirection, with interventions including protecting the rights and safety of others, documenting interventions, and providing sensory items and domestic chores as needed. Despite these identified behaviors and care plan interventions, review of progress notes and behavior tracking tasks from 01/23/26 through 02/23/26 showed no behavior documentation for 02/13/26, the date staff alleged the resident was in another resident’s room playing with that resident’s bed remote and bed bolster at the time of the other resident’s fall. An IDT summary note for the other resident dated 02/16/26 documented that the other resident was found on the floor bleeding and yelling out, with staff reporting they had recently assisted her to bed in a low position with the bed against the wall and a bolster on the open side, and that upon re-entering the room, the bed was in a different position and the cognitively impaired resident was present in the room. The DON confirmed that nurses document behaviors in progress notes and CNAs document behaviors under the task tab, and verified there was no behavior note in the cognitively impaired resident’s record for 02/13/26 describing her presence in the other resident’s room or interaction with the bed remote or bolster as alleged.
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