Failure to Update Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to address sexual behaviors directed towards others, which could constitute abuse. Specifically, a review of a facility-reported incident showed that one resident was found in another resident's room, with the second resident's hand on the first resident's genitals. Despite this incident, the comprehensive care plan for the resident involved did not include any focus area, goals, or interventions related to sexual behaviors or the potential for sexual abuse towards others. The care plan only addressed manifestations of bipolar disorder, such as shouting and wandering, but omitted any mention of sexual behaviors. During an interview, a staff member confirmed that the resident's sexual behaviors had not been added to the care plan and acknowledged that such behaviors should have been care planned. Facility policies reviewed indicated that care plans are to be developed and revised upon a resident's status change, but this process was not followed in this case. The deficiency was identified through both interview and record review, with documentation supporting that the care plan was not updated as required.