Failure to Maintain Accurate Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to ensure that two residents had accurate and up-to-date care plans, as required by policy. One resident with a history of sexually inappropriate touching of other residents was observed engaging in physical contact with another resident, but his care plan was not updated to reflect inappropriate sexual behaviors. The care plan for this resident previously included impaired behavior related to touching other residents, but this was marked as resolved and not revised to address ongoing or new concerns. The resident's Minimum Data Set (MDS) also did not indicate behaviors directed toward other residents, despite documented incidents. Another resident, who had dementia with behavioral disturbances and daily wandering behaviors, did not have any care plan interventions addressing sexual inappropriateness, even though she was involved in the observed incident. Staff interviews confirmed that the care plans were not appropriately updated and that there was uncertainty regarding the resolution and documentation of behavioral issues. The facility's policy required comprehensive, person-centered care plans to be developed and revised based on assessment findings, but this process was not followed for these residents.