Failure to Identify and Care Plan for Inappropriate Sexual Behaviors in a Resident with Dementia
Penalty
Summary
The facility failed to identify, monitor, and develop individualized interventions for a resident with dementia who exhibited inappropriate sexual behaviors. The resident, who had diagnoses including moderate unspecified dementia with behavioral disturbances, depression, anxiety, delusional disorder, and pseudobulbar affect, was noted to have daily behavioral symptoms that had worsened compared to previous assessments. Despite multiple care plans addressing general behavioral disturbances, agitation, and memory impairment, there was no care plan or documentation specifically addressing the resident's sexually inappropriate behaviors. An incident occurred in which the resident fondled another resident's groin and subsequently sat on his lap and bounced up and down. Staff intervened and redirected the resident, but the incident was not reported to the DON or Administrator at the time. The clinical record lacked documentation of the inappropriate sexual behaviors, and there was no behavior monitoring or care plan related to these specific behaviors. Interviews with staff and administration confirmed the absence of documentation and individualized interventions for the sexually inappropriate behaviors. Facility policies required comprehensive, person-centered care plans to address each resident's risks and needs, including behavioral issues, and mandated documentation of behavioral incidents and interventions. However, the facility did not follow these procedures in the case of this resident, as evidenced by the lack of a care plan and documentation for the sexual behavior expressions, despite staff awareness and intervention during the incident.