Failure to Monitor and Document Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to adequately monitor, document, and prevent a resident's inappropriate sexual behaviors, despite clear evidence of ongoing incidents. The resident, who had a history of dementia with behavioral disturbances, agitation, and other psychiatric diagnoses, exhibited sexually inappropriate behaviors on multiple occasions as documented by CNAs. However, these behaviors were not thoroughly documented in the resident's progress notes, and there was a lack of detailed reporting regarding the nature of the incidents. The care plan included interventions for these behaviors, but physician orders did not specifically address monitoring for sexual behaviors, and staff documentation was inconsistent and incomplete. Observations revealed the resident engaging in inappropriate physical contact with another resident in a common area, with staff present but not intervening until prompted. Interviews with staff confirmed awareness of the resident's behaviors and the expectation for detailed documentation and reporting, which was not consistently followed. The DON acknowledged that aides' documentation of sexual behaviors was vague and that more detailed notes and reporting to responsible parties were necessary. The failure to monitor, document, and prevent these behaviors constituted a deficiency in providing necessary behavioral health care and services.