Failure to Update Care Plan and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to revise and update a resident's care plan and implement effective interventions to ensure that residents were free from abuse. Over a period of more than six months, staff and the social worker documented multiple incidents of a resident engaging in sexually inappropriate behaviors, including entering female residents' rooms without permission, making inappropriate comments, and touching other residents inappropriately. Despite these repeated incidents, the facility did not identify or report these actions as abuse, nor did it take sufficient action to prevent further occurrences. Progress notes and grievance logs revealed that staff repeatedly redirected the resident and discussed the inappropriate behaviors with him, but the care plan was not updated to reflect new interventions or strategies to address the ongoing issues. The care plan initially included general interventions such as administering medications and approaching the resident calmly, but these were not revised in response to the continued incidents. The facility also failed to report the incidents to the appropriate authorities, such as OHFLAC and APS, as required. Interviews with staff and administration confirmed that the care plan had not been updated to address the resident's behaviors and that there was a lack of clarity regarding reporting responsibilities. The social worker and DON acknowledged awareness of the complaints and incidents but did not ensure that the care plan was revised or that effective measures were implemented to protect other residents from further abuse.