Failure to Assess Consent and Develop Care Plans for Resident Relationships
Penalty
Summary
The facility failed to assess and document the ability of two residents to consent to a resident-to-resident relationship and did not establish individualized, resident-centered care plans addressing their relationship. Resident B, who had a history of stroke and behavioral disturbances and was assessed as having moderate cognitive impairment, reported being in a relationship with Resident C, which included holding hands, playing cards, and kissing. However, there was no documentation in Resident B's clinical record regarding an assessment of her ability to consent to this relationship or a care plan addressing her sexuality and relationship with Resident C. Similarly, Resident C, who had diagnoses including chronic obstructive pulmonary disease and depression and was assessed as cognitively intact, also reported being in a relationship with Resident B, which involved spending time together and kissing. The clinical record for Resident C also lacked documentation of an assessment of his ability to consent and a care plan for his sexuality and relationship with Resident B. The Executive Director confirmed that there was no documentation of capacity to consent or care plans for either resident, despite facility policy requiring such assessments and documentation.