Failure to Develop and Implement Comprehensive Care Plan for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate physical contact with other residents. The care plan did not specify the exact behaviors to be monitored during one-to-one supervision, nor did it provide clear, resident-centered interventions or define the duration and criteria for discontinuing the supervision. The lack of specificity in the care plan was confirmed during interviews with nursing staff and the Assistant Director of Nursing, who acknowledged that the care plan's directive to monitor for episodes of inappropriate touching was vague and not tailored to the resident's actual behaviors. Observations and interviews revealed that the one-to-one supervision outlined in the care plan was not consistently implemented. On multiple occasions, the resident was observed without a staff member providing the required one-to-one supervision. Staff interviews indicated that the assigned sitter was sometimes absent, and coverage was not always provided as required by the care plan. One staff member admitted to monitoring the resident from the hallway while performing other duties, rather than providing continuous, direct supervision as specified. The resident involved had a history of cognitive impairment and required moderate assistance with activities of daily living. The care plan was initiated after incidents of inappropriate touching were reported by another resident, who described multiple episodes of unwanted physical contact. Despite the care plan and orders for one-to-one monitoring, facility staff failed to ensure that supervision was maintained at all times, and the care plan lacked the necessary detail to guide staff in effectively monitoring and addressing the resident's behaviors.