Failure to Implement Behavioral Health Interventions for Resident with Sexual Behaviors
Penalty
Summary
The facility failed to implement appropriate behavioral health care and interventions for a resident with a complex medical and psychiatric history, including anoxic brain damage, dementia, bipolar disorder, major depressive disorder, PTSD, and substance abuse. The resident had a documented history of sexually inappropriate behaviors, and the care plan included interventions such as medication administration, behavioral health involvement as needed, monitoring for wandering, education on safe practices, and immediate removal from situations with 1:1 supervision when necessary. Despite these interventions being listed, staff interviews revealed that preventive measures were not in place prior to an incident where the resident engaged in inappropriate sexual behavior with another resident. Staff were unsure who witnessed the incident, and there was a lack of clarity regarding the implementation of preventive strategies before the event occurred. Following the incident, the resident was placed on 1:1 supervision for a short period and then on 15-minute checks, but no alternative or individualized behavioral interventions were documented prior to moving the resident to another unit. Psychosocial assessments for the involved residents were completed verbally but not documented at the time, and witness statements were used retrospectively for documentation. The deficiency was identified based on the lack of documented and implemented behavioral health interventions prior to the incident, as well as insufficient preventive measures to address the resident's known behavioral risks.