Failure to Care Plan and Document Behavioral Health Needs
Penalty
Summary
The facility failed to care plan and document a resident's sexually inappropriate behaviors and did not ensure that the physician or Certified Nurse Practitioner (CNP) addressed these behaviors. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic heart failure, bipolar disorder, and severely impaired cognition, exhibited repeated sexual behaviors towards other residents, including entering female residents' rooms without permission and inappropriate physical contact. Despite multiple documented incidents and a physician order for increased supervision, the resident's care plan did not address these behaviors, and there was no documentation in the medical record regarding a significant incident or the rationale for one-on-one supervision. Additionally, progress notes from the physician and CNP did not indicate awareness or management of the resident's behaviors, even though the CNP later confirmed knowledge of the incidents and interventions. Interviews with staff confirmed that the resident's behaviors were known but not documented or addressed in the care plan or medical record. The administrator verified the lack of documentation and care planning related to the resident's behaviors and confirmed that no medication interventions were attempted.