Failure to Document Behavioral Interventions After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to document behavioral interventions as indicated on the care plan for a resident following an altercation with another resident. Resident 1 was admitted with diagnoses including anemia and schizoaffective disorder and had a documented episode of increased aggression on 2/28/2026, during which he was unable to be redirected and was considered a danger to others. On that date, Resident 1 entered Resident 2’s room, and RN 1 responded after hearing Resident 1 screaming in the hallway. RN 1 found Resident 2 holding a foldable chair, and Resident 1 reported that Resident 2 had hit him on the head with the chair. Resident 2 had been admitted with chronic kidney disease and hypertensive urgency. Resident 1’s care plan, dated 2/28/2026, included interventions for staff to provide early redirection and de-escalation techniques to reduce episodes of verbal aggression. Record review of Resident 1’s progress notes for 2/28/2026 showed that the incident occurred at 11:20 a.m. and that Resident 1 was picked up for transfer at 4:45 p.m., but the notes did not document any early interventions, redirection, or de-escalation measures taken during the period when Resident 1 was intermittently yelling while awaiting transfer. RN 1 acknowledged that the progress notes did not indicate early interventions, redirection, or de-escalation that were done during Resident 1’s episodes of screaming. The ADON confirmed that Resident 1 was alert, oriented, ambulatory, and had episodes of screaming on 2/28/2026, and stated that the progress notes did not document interventions, including non-pharmacological ones. The DON stated that care plan interventions should have been documented if they were completed and that following care plan interventions was important to prevent further behavioral escalation and to keep residents and staff safe. The facility’s policy on Behavioral Assessment, Intervention, and Monitoring required that any improvements or worsening in behavior, mood, and function, as well as new or emergent symptoms, be documented and reported.
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