Failure to Manage and Supervise Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that residents with behavioral health needs, including those exhibiting aggressive, wandering, and sexually inappropriate behaviors, were properly managed and supervised to protect other residents from abuse and to maintain their safety and privacy. One resident with severe cognitive impairment and a history of inappropriate sexual behaviors, including masturbation and wandering, was found by an LPN in another resident's room, undressed from the waist down and caressing the other resident's hip and thigh. Staff and family members had previously observed and reported this resident's sexually inappropriate behaviors, but these were not effectively communicated or care planned to prevent such incidents. Interviews with staff revealed a lack of awareness and inconsistent knowledge about the resident's behaviors, and the care plan did not include specific interventions to address the risk of the resident entering other residents' rooms. Additional deficiencies were identified involving other residents with behavioral disturbances. One resident with Alzheimer's disease and severe cognitive impairment became agitated and physically assaulted another resident, hitting them multiple times in the back and head. Staff had noted the resident's increasing agitation and combative behavior, but the care plan did not specify the level of supervision or interventions required to prevent such incidents. Staff interviews indicated that the resident's behaviors were known, but supervision was limited to periodic checks and monitoring in common areas, which proved insufficient to prevent the physical altercation. Another incident involved a resident with dementia and behavioral disturbance who entered another resident's room, initiated an altercation, and took a personal item. This resident had a documented history of aggressive and combative behavior toward staff and other residents, including cursing, slapping, and spitting. Despite these behaviors, the care plan did not include interventions or supervision levels to prevent the resident from affecting others. Staff and administrative interviews confirmed the presence of behavioral issues but did not recall or implement specific measures to address the risks posed by these behaviors.