Failure to Revise Care Plans for Residents with Sexual Offender Status
Penalty
Summary
The facility failed to ensure that care plans for residents with a history of sexual offenses were specific, comprehensive, and revised to include individualized behaviors, restrictions, and interventions. Four residents with sexual offender status were reviewed, and in each case, their care plans lacked detailed information about their specific sexual offender history, the nature of their offenses, and any individualized restrictions or interventions required. The care plans contained only general interventions such as monitoring for inappropriate sexual behaviors, involving residents in activities, and encouraging appropriate communication, without addressing resident-specific risks or restrictions. For example, one resident with moderate cognitive impairment and a history of multiple sclerosis was listed as a sex offender, but their care plan did not specify their offense or any unique restrictions. Another resident, identified as a sexually violent predator and cognitively intact, had a care plan that did not include details about their specific behaviors or restrictions, despite a history of verbal aggression and medication refusal. A third resident with psychoactive substance abuse and a history of noncompliance had a care plan focused on physical aggression, with no mention of their sexual offender status or related restrictions. A fourth resident, who was later discharged for parole violations involving prohibited electronic devices and inappropriate images, also had a care plan lacking individualized details about their sexual offender history and restrictions. Interviews with facility staff revealed a lack of clear communication and documentation regarding which residents were sexual offenders and what specific restrictions applied to them. Staff often learned about residents' offender status informally, and restrictions were not consistently incorporated into care plans or communicated to all staff. The facility's policies required care plan revisions and safety plans for offenders, but these were not effectively implemented, resulting in care plans that did not address the unique needs and risks associated with residents who were sexual offenders.