Failure to Timely Revise Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan addressing a resident's sexual behaviors following a significant incident. The resident, who had Alzheimer's disease and was deemed incompetent to make medical decisions, exhibited severe mental impairment as indicated by low BIMS scores. On one occasion, the resident was found in bed with a female resident, with his hand down her pants. Although staff attempted to keep the resident separated from female residents and initiated one-on-one supervision, this intervention was not formalized through a physician's order or documented in the care plan. There was no clear communication or documentation to ensure all staff were aware of the supervision requirement. Subsequent incidents occurred, including the resident being found naked in bed with another female resident, again without evidence of one-on-one supervision being in place. Interviews with staff revealed confusion and lack of awareness regarding the supervision status, and assignment sheets did not reflect any one-on-one supervision for the resident. The care plan was not updated to address the resident's sexual behaviors and the need for one-on-one supervision until after these incidents had occurred, indicating a failure to timely revise the care plan in response to the resident's behaviors.