Failure to Develop and Implement Comprehensive, Person-Centered Care Plans for Resident Relationships
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents who were involved in romantic or sexual relationships with other residents. Several care plans were either not initiated in a timely manner or lacked specific interventions and boundaries regarding the relationships. For example, one resident with cognitive communication deficit and major depressive disorder was involved in an incident of inappropriate sexual behavior with another resident, but his care plan was not updated until a week after the incident and did not address boundaries for the relationship. Another resident with muscle weakness and adult failure to thrive had a care plan that did not address his relationship with a specific female resident, despite documented episodes of hypersexuality and staff observations of inappropriate physical contact. Similarly, a resident with cognitive communication deficit and depression had a care plan that was only recently initiated and did not specify boundaries for her relationship with a male resident, even after staff witnessed inappropriate touching in public areas. Staff interviews confirmed a lack of awareness regarding established boundaries for these relationships, and social services staff admitted to forgetting or missing updates to the care plans. Additionally, two residents with dementia, depression, and cognitive communication deficits were in a long-term relationship involving sexual interactions, but their care plans were not updated to reflect boundaries or interventions until much later. Staff, including CNAs and nurses, reported not knowing what boundaries were in place and relied on care plans for this information, which were not kept current. The facility's own care planning policy requires individualized, resident-centered plans that communicate needs to direct care staff, but this was not consistently followed, resulting in unmet care needs and the potential for negative outcomes.
Plan Of Correction
F656 Develop/Implement Comprehensive Care Plan Resident #102 still resides in the facility. Care plan was reviewed and updated as needed. Resident #103 still resides in the facility. Care plan was reviewed and updated as needed. Resident #104 still resides in the facility. Care plan was reviewed and updated as needed. Resident #105 still resides in the facility. Care plan was reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be meet with to discuss what level of relationship to have and have been care planned. If resident has a guardian or DOPA, the will be meet with to discuss what level of relationship they permission for the residents to have and have been care planned. Any concerns identified will be addressed immediately. IDT has been re-educated on the Care Plan Policy. Care Plan Policy was reviewed by the QA committee and deemed appropriate. IDT will meet weekly to review residents who appear to be in a relationship care plans for any changes needed weekly x 4, then monthly and findings will be reported to QA committee for further recommendations. Administrator is responsible for sustained compliance.