Failure to Develop Behavior Care Plan for Inappropriate Sexual Conduct
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the behavioral needs of a resident who exhibited inappropriate sexual behaviors. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 8 out of 15, was involved in an incident where he made sexual remarks and verbalized intentions of sexual misconduct toward an LPN in a shared gathering room. The incident was witnessed by other residents and staff, and law enforcement was involved, resulting in the arrest and removal of another resident who also participated in the behavior. Despite the incident and the resident's documented cognitive impairment, the facility did not update the resident's comprehensive care plan to include goals or interventions related to inappropriate sexual behaviors. The care plan, last reviewed after the incident, lacked any mention of monitoring or addressing such behaviors. Facility leadership acknowledged that no interventions or monitoring had been implemented for the resident's inappropriate sexual comments, despite recognizing that such measures should have been in place.