Failure to Update Care Plan After Sexually Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to update the care plan for a resident with a known history of sexually inappropriate behaviors following multiple incidents of inappropriate touching involving other residents. Despite documented incidents, including one where the resident placed their hand under another resident's shirt and rubbed their breast area in the dining room, the care plan did not include interventions to prevent recurrence of such behaviors. The resident had previously been sent to a behavioral health hospital after similar incidents, but no new interventions were added to the care plan upon their return or after subsequent events. The resident's medical record showed a history of cerebral infarction, hemiplegia, peripheral vascular disease, COPD, bipolar disorder, anxiety, sexual dysfunction, unspecified psychosis, and depression. The resident was moderately impaired cognitively and required substantial to maximal assistance with most activities of daily living. Progress notes documented repeated inappropriate behaviors, including touching and tickling other residents, and staff had to redirect the resident on multiple occasions. Staff interviews revealed a lack of awareness and documentation regarding the need for monitoring the resident for sexual behaviors. The LPN interviewed was unaware of any residents requiring such monitoring and did not view the resident's behaviors as concerning. The DON provided a monitoring form that was incomplete and lacked evidence of one-on-one monitoring. The care plan, even after being updated during the survey, still did not include specific interventions to prevent recurrence of sexually inappropriate behaviors.