Failure to Monitor Behaviors of Resident on Sex Offender Registry
Penalty
Summary
Facility staff failed to provide appropriate monitoring and care for a resident who was listed on the sex offender registry. The resident was admitted with multiple medical diagnoses, including ischemic cardiomyopathy, CHF, atrial fibrillation, and an LVAD, and was assessed as cognitively intact with a BIMS score of 15. The care plan addressed behavioral issues related to refusal of cardiac care but did not include interventions specific to monitoring for sexual or inappropriate behaviors. During the survey, it was determined that although the facility had a policy requiring behavioral assessment and monitoring, there was no evidence that staff monitored or documented the resident's behaviors related to their status on the sex offender registry. Interviews with administrative and social work staff confirmed that while the facility previously admitted residents on the sex offender registry, there was no process in place for ongoing monitoring of such residents' behaviors. Staff acknowledged that behaviors should be monitored and documented, but no such monitoring was found in the resident's records. The facility's own policy required assessment and monitoring of behaviors, but this was not implemented for the resident in question.