Failure to Develop Comprehensive Care Plans for Resident Sexual Activity
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing sexual activity and relationships for several residents, despite evidence of known sexual relationships and interactions among residents. Specifically, five residents with varying degrees of cognitive impairment and mental health diagnoses were identified as being involved in sexual relationships or behaviors, yet their care plans did not include measurable objectives, timeframes, or interventions related to sexual behavior or relationships. The care plans reviewed either omitted this aspect entirely or only addressed unrelated behavioral issues. Interviews with staff, including the DON, ADON, and MDS Coordinator, revealed that while staff were aware of consensual sexual relationships among residents and sometimes provided education on consent and safe sex, these interactions were not consistently documented or care planned. Staff described providing privacy and condoms to residents they believed were capable of consenting, but there was no evidence of formal assessments or care plan interventions to guide staff actions or ensure resident needs were met in this area. Some staff believed care plans were in place, but upon review, these were either missing or incomplete regarding sexual activity. The facility's policy on care planning required the development of individualized, comprehensive care plans based on resident assessments, with input from the interdisciplinary team and, when possible, the resident and their representatives. However, the policy did not specifically address acute care plans for issues not covered by the comprehensive assessment, such as sexual relationships. As a result, the lack of care planning for known sexual activity among residents represented a failure to meet regulatory requirements for comprehensive, person-centered care planning.