Failure to Update Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to include individualized interventions related to behaviors after a reported sexual event. The incident involved a resident who was observed performing a sexual act on another resident. Despite having a documented history of self-exposure, these behaviors were not added to the care plan prior to the incident. The care plan only included general interventions for reducing episodes of self-exposure, without specific measures to prevent future incidents of sexual behavior. The resident in question had a complex medical history, including diagnoses of muscle wasting, anxiety disorder, major depressive disorder, unspecified dementia, and cognitive communication deficit. Despite these conditions, the care plan did not reflect the resident's known behaviors of self-exposure and sexual acts. The psychiatric assessments and progress notes indicated a history of exposing himself to female residents, yet this information was not communicated effectively to the interdisciplinary team or incorporated into the care plan. Interviews with staff revealed a lack of awareness and communication regarding the resident's behaviors. The Advanced Practice Registered Nurse (APRN) was not informed of the resident's history of sexual behaviors prior to the incident. The Nursing Home Administrator (NHA) acknowledged that the care plan could be more meaningful and confirmed that no specific interventions were in place for the sexual act observed. The facility's policy required the care plan to be updated based on changing needs, but this was not adhered to, leading to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider for the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F656 Develop/Implement Comprehensive Care Plan What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Facility updated Care Plan of resident #1 on How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: 1. An in-house quality review was completed to ensure residents exhibiting behaviors have accurate and updated care plans with a focus of ensuring a person-centered approach with resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment. Any outstanding issues or concerns were addressed as they were identified. What measures will be put in place or what systematic changes you will make to ensure that the practice does not recur: 1. The Regional Director of Clinical Services in-serviced the Interdisciplinary Team (IDT) on the components of this regulation and the facility policy regarding plans of care with an emphasis on person-centered care. 2. Facility staff were reeducated by the Assistant Director of Nursing/designee on Plans of Care policy and procedure with an emphasis on person-centered care. 3. Newly hired employees and contract staff will receive education during orientation. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: During Morning meeting, the Director of Nursing (DON) and/or designee will review occurrence of behaviors documented from the previous day, and/or post psychiatry documentation review, to ensure Care Plans are updated accordingly, daily 5 times a week for 4 weeks, then weekly for 4 weeks, then random Care Plans every other week, to ensure Care Plans are person-centered and accurate, until the QAPI committee finds that the facility has met substantial compliance. Date Certain: