Failure to Develop Behavioral Care Plan for Resident on 1:1 Supervision
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavioral issues, specifically following an incident involving inappropriate sexual behavior. The resident in question had a history of medical conditions including diabetes mellitus, stroke with ataxia, depression, and anxiety, and was admitted with intact cognition. After an incident where the resident made a gyration motion in another resident's doorway, the facility placed the resident on one-on-one (1:1) supervision per physician order, and this supervision continued for several days as documented in health status notes. Despite the ongoing 1:1 supervision and the resident's behavioral concerns, a review of the resident's care plan revealed that there were no documented interventions or care plans addressing the resident's behaviors or the need for 1:1 supervision. The lack of a behavioral care plan was confirmed by the MDS Coordinator, who acknowledged that such a plan should have been created given the circumstances. The facility was also aware of a pending court hearing for sexual misconduct involving the resident prior to admission, but this information did not result in a behavioral care plan being developed. The deficiency was discovered during a complaint investigation, which included review of the facility's self-reported incident, medical records, and staff interviews. The investigation also noted that the facility conducted an internal investigation into the allegation of sexual abuse, which was ultimately unsubstantiated. However, the failure to create a behavioral care plan for the resident, despite clear evidence of behavioral issues and the implementation of 1:1 supervision, constituted noncompliance with regulatory requirements for comprehensive care planning.
Plan Of Correction
Resident #11 was discharged from the facility prior to survey visit so the care plan/intervention was unable to be completed. However, on 6/18/2025, the MDS nurse and administrator educated the social service director on the importance of behavior care plans. She was shown the focus, goal, and adding interventions. A new care plan library was created on 6/15/2025 to streamline the process. With no other residents on a 1:1, there are no like residents to audit. Behavioral care plans on all similar/like residents will be audited by the MDS nurse twice a week for two weeks, then once a week for two weeks, and the results will be reviewed in QAPI. Social Services and MDS coordinator completed audits of like residents from 6/18/2025 to 7/9/2025.