Failure to Initiate Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to initiate a care plan for a resident who exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. The resident had a history of severe dementia with psychotic disturbance, unspecified psychosis, depression, and delirium, and was admitted to the facility following psychiatric evaluation for bizarre behavior and significant cognitive impairment. Despite these behaviors being observed and reported by nursing staff, no care plan was developed to address or manage the resident's hypersexual behavior. Interviews with staff revealed that the inappropriate behavior was known to the nursing team, and it was reported to the previous Director of Nursing. Staff acknowledged the behavior as related to the resident's dementia diagnosis but did not consider it sexual abuse. The affected resident who witnessed the behavior reported feeling uncomfortable and unsafe, and communicated these concerns to the nursing staff, who advised using the call light if further incidents occurred. However, there was no evidence in the medical record that a care plan was initiated to address the behavior or to protect other residents. Facility policies required that significant changes in a resident's condition, including behavioral changes, be assessed and addressed through interdisciplinary care planning. The policies also specified that such changes should be documented and that a comprehensive assessment should be conducted. Despite these requirements, the facility did not develop or implement a care plan for the resident's inappropriate sexual behavior, resulting in a deficiency related to the failure to meet the resident's needs and ensure the safety and well-being of other residents.