Failure to Provide Behavioral Health Services and Interventions for Sexual Aggression
Penalty
Summary
The facility failed to ensure that a resident with a history of severe cognitive impairment, catatonic schizophrenia, anxiety disorder, and a diagnosis of hypersexuality received necessary behavioral health care and services. Despite documented evidence of worsening sexual behaviors and sexual aggression, there were no physician orders or interventions in place to monitor or address these behaviors. The resident's care plan did not include specific problems, care areas, or interventions related to sexual abuse, sexual aggression, or sexual behaviors, and there was no revision to the care plan after documentation of sexually aggressive behaviors. Staff interviews and record reviews revealed that nonpharmacological interventions for sexual behaviors were not implemented or documented, even though behavioral health services had recommended such interventions. The resident exhibited inappropriate sexual behaviors, including making sexual comments to staff, attempting to kiss a nurse, and stating intentions to commit sexual assault. On one occasion, the resident sexually abused another resident in her room, and staff had to physically intervene to stop the incident. Documentation also showed that staff had been threatened by the resident in the weeks leading up to the incident. Although staff could describe examples of nonpharmacological interventions for managing sexual behaviors, these interventions were not put into practice for the resident in question. The care plan only referenced inappropriate sexual behavior under a general behavior category, without individualized or targeted interventions. The lack of appropriate assessment, care planning, and implementation of nonpharmacological interventions contributed to the opportunity for the resident to sexually and physically abuse another resident.
Removal Plan
- R121 was discharged from the facility and was arrested and did not return to the facility.
- The Assistant Administrator, DON, Division [NAME] President, and the medical director reviewed the facility's policy titled Behavioral Health. No revisions were indicated through review.
- An audit was completed by DN for residents with sexual inappropriate behaviors complete of all patients. A review of the plan of care was completed to ensure that nonpharmacological interventions were captured for residents that exhibited behaviors. A referral was initiated as appropriate by the DON.
- In-service education was initiated for RNs and LPNs and included identifying behavioral health needs, updating the plan of care and implementing interventions in the plan of care as outlined in the facility's Behavioral Health Policy to include nonpharmacological interventions. CNAs provided education on abuse reporting to include sexual inappropriate behaviors. Education was provided by the DON, Assistant Director of Nursing, Nurse Manager, or Social Services Director. All RNs, LPNs, CNAs, and CMAs have been in serviced. No staff shall work until they have completed in-service education. No new hires.
- An audit tool was developed by DON to review patients with inappropriate behaviors to ensure they have a non-pharmacological intervention noted on care plan. Any noncompliance noted will be addressed through written education by assistant administrator and/or DON.