Failure to Address and Care Plan Resident Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's sexual behaviors, resulting in the absence of goals, interventions, or plans for safe sexual activity, assessment of competency for consent, redirection from other residents, and protection from unethical staff. Despite multiple documented incidents of inappropriate sexual behaviors, including public sexual acts and sexual contact with both staff and other residents, the care plan did not reflect these behaviors or provide specific interventions to address them. The care plan only noted the resident as sexually active and included general statements about respecting privacy during sexual activity with consenting partners, without addressing the resident's cognitive impairment or the need for consent assessment. The resident in question had a history of stroke, hemiplegia, moderate dementia, major depressive disorder, mood disorder, and anxiety disorder, with consistently low BIMS scores indicating severe to moderate cognitive impairment. Multiple MDS assessments failed to identify any sexual behaviors, despite staff and witness reports of ongoing inappropriate sexual conduct. Staff interviews and documentation revealed that the resident engaged in repeated sexual behaviors, including grabbing and touching staff and other residents, and was involved in an incident of oral sex with an employee. However, there were no physician orders for safe sex education, STD screening, or competency evaluation for sexual consent. Interviews with staff, including the DON, Administrator, and APRNs, confirmed that the resident's sexual behaviors were known and discussed, but no formal interventions or care plan updates were made to address these behaviors until after a significant incident occurred. Staff relied on informal redirection and discussions with the resident's representative, but there was no policy or procedure in place to manage such behaviors, nor were there documented interventions to prevent further incidents or protect the resident and others from harm.