Incomplete and Inaccurate Documentation of Behavioral Event and Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its charting and documentation policy. For one resident with rheumatoid arthritis, failure to thrive, depression, anxiety, and PTSD, the quarterly MDS showed the resident was cognitively intact with moderate depression and dependent on staff for toileting hygiene, showers, and transfers. A progress note documented that the resident was exhibiting hallucinations and making accusations that staff were stealing belongings, drugging her, and transferring her against her will, and that she had called EMS to report people were “messing with” and stealing her furniture. However, this progress note did not document that the resident was pink slipped by the physician for psychiatric evaluation. A hospital summary later showed that the resident arrived via EMS with a pink slip from the facility citing agitation, threats toward staff, refusal of care, hallucinations, and paranoia, indicating a discrepancy and omission in the facility’s medical record. For another resident with type II diabetes, Alzheimer’s disease, cognitive communication deficit, hip pain, and anxiety, the quarterly MDS indicated cognitive impairment and a need for limited assistance with eating, toileting, showering, and transfers. The care plan identified impaired cognitive function and thought processes related to Alzheimer’s disease, with interventions including medication administration as ordered and cueing, reorientation, and supervision as needed. A Self-Reported Incident documented a resident-to-resident altercation in a secured unit, in which this resident reported being pushed by another resident; staff intervened, separated, and redirected both residents, and assessed them with no injuries, and the incident was ultimately unsubstantiated. Despite this, there was no corresponding documentation in the resident’s progress notes regarding the allegation of resident-to-resident abuse or the altercation. The DON confirmed the absence of documentation for both the pink slip for the first resident and the altercation involving the second resident, contrary to the facility’s policy requiring documentation of changes in condition, events, incidents, or accidents involving residents.
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