Failure to Develop and Implement Care Plan for Sexually Inappropriate Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's sexually inappropriate behavior, specifically the act of touching his private area and making inappropriate requests to a staff member. The resident, who had diagnoses including paranoid schizophrenia and violent behavior, was assessed as having moderate cognitive impairment and required supervision for several activities of daily living. Despite an incident being observed and reported by a 1:1 sitter, there was a delay in reporting the behavior to nursing staff, and no care plan interventions were initiated to address the inappropriate sexual behavior. Interviews with nursing staff confirmed that the incident should have been reported immediately and that a resident-centered care plan should have been developed and implemented to ensure the safety of the resident and others. A review of facility policy indicated that care plans must be updated to address changes in behavior, but this was not done following the incident. The lack of timely reporting and failure to initiate appropriate care planning placed other residents at risk.