F0740

D

Failure to Document and Monitor Behavioral Symptoms for Two Residents

Indianapolis, Indiana Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document and monitor behavioral health symptoms as ordered and care planned for two residents with identified behavioral health needs. Resident D had diagnoses including dementia and bipolar disorder, with a physician’s order dated 4/24/25 directing staff to monitor each shift for specific behaviors such as delusions, hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. A quarterly MDS dated 1/9/26 showed moderately impaired cognition and no behaviors during the assessment period, while a care plan revised on 1/21/26 identified multiple behavioral symptoms and directed staff to evaluate behavioral symptoms and intervene when inappropriate behavior was observed. Despite this, the February 2026 MAR indicated no behaviors for the month, and the clinical record lacked a behavior note addressing a resident‑to‑resident bodily contact incident in which Resident D struck another resident.

On 2/24/26, an incident report in the facility’s investigation file documented that Resident D made contact with another resident’s head using an open hand, with no injuries reported. The Social Services Director stated that Resident D was not normally aggressive and that when a resident exhibits new behaviors, the nurse should document the behavior in the clinical record using a behavior progress note so it can be reviewed in the morning meeting. The Interdisciplinary Team discussed the incident but did not identify a root cause, and there were no new care plans or interventions added to Resident D’s behavior care plan following the event. LPN 12, who separated the residents, reported that another resident had witnessed the incident, that Resident D did not deny hitting the other resident, and that Resident D stated the other resident would not be quiet, which LPN 12 assumed was the reason for the behavior.

The facility also failed to document and track behaviors for Resident B, who had a diagnosis including a personality disorder and was cognitively intact per a quarterly MDS dated 12/16/25. A physician’s order dated 8/12/25 required staff to monitor and track a range of behaviors, including calling emergency services, false accusations/beliefs, anxiety, tearfulness, insomnia, refusal of care, verbal aggression, throwing objects, OCD behaviors, crying, verbal expressions of sadness, racial slurs, self‑isolation, anger, yelling, and cursing, and to implement interventions such as redirection, snacks, fluids, diversionary activities, toileting, change of environment, pain assessment, rest, and comfort. The March 2026 MAR/TAR indicated no behaviors as of 3/11/26; however, during an observation and subsequent interview, Resident B was curt, then later screamed and yelled at an LPN about medication, and the LPN was unsure why the resident was upset. Resident B’s clinical record lacked documentation of this behavior and lacked any documented interventions implemented at that time, despite facility policy stating that nursing monitors for target behaviors daily and documents them, and that nurses should document behaviors on the MAR to trigger a progress note.