Failure to Document and Address Sexual Behaviors and Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of mental health disorders, substance use, and behavioral issues. An incident occurred in which the resident made inappropriate sexual advances toward another resident who had moderate cognitive impairment. The incident was not documented in the clinical record, and there was no evidence that the care plan was updated to address sexual behaviors or that the resident was monitored for such behaviors following the event. Interviews revealed that staff, including the Social Services Director and Certified Nurse Aides, were either unaware of the incident or did not document the behaviors and follow-up actions. The Director of Nursing acknowledged that a report was made about the incident and that capacity for sexual consent assessments were completed for both residents, but there was no documentation of the incident, investigation, or subsequent monitoring in the clinical records. Additionally, the family of the resident with cognitive impairment was not notified of the incident, despite claims to the contrary. The facility's documentation systems, including progress notes and care plans, lacked information about the sexual incident, the behaviors exhibited, and the interventions or monitoring implemented. The facility's policies required investigation, documentation, and care plan updates in response to such incidents, but these procedures were not followed. As a result, the necessary behavioral health services and protections were not provided to the residents involved.