Failure to Identify and Address Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to identify, document, and implement prevention interventions for inappropriate touching behaviors exhibited by a resident towards other residents. Specifically, a male resident with diagnoses including Parkinson's, dementia, anxiety, and depression, was observed on multiple occasions engaging in inappropriate physical contact with female residents, including hand holding, rubbing shoulders, and placing his hand up another resident's pant leg. Despite these incidents, there was no documentation of specific interventions to prevent recurrence or protect the residents involved, and the care plan lacked details on the types of behaviors to monitor, frequency of monitoring, or behavioral clues to observe. The records show that the resident's care plan was not updated to reflect the inappropriate behaviors or to provide clear guidance to staff on how to address or prevent such incidents. The care plan also did not specify how the resident expressed depression or anxiety, nor did it include interventions tailored to the observed behaviors. Staff interviews revealed that while some staff were aware of the incidents, there was inconsistent communication and documentation regarding the behaviors, and the social services department was not consistently notified or involved in follow-up. Additionally, behavior monitoring flowsheets did not include inappropriate touching as a targeted behavior, and there was no evidence that the psychiatric nurse practitioner was informed of the specific incidents. The female resident involved, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to recall the incident and showed no signs of distress during subsequent assessments. However, her care plan was not updated to address the incident or to include interventions to prevent further occurrences. The facility's policy required close monitoring and individualized care planning for behavioral health issues, but this was not followed in practice, as evidenced by the lack of documentation, care plan updates, and specific interventions after the incidents.