Failure to Update and Implement Comprehensive Care Plan for Resident with Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address the nursing, mental, and psychosocial needs of a resident who exhibited sexually inappropriate behaviors. Despite multiple incidents of the resident inappropriately touching other residents over a four-month period, the care plan was not revised in a timely or adequate manner to reflect new interventions or increased supervision. Nursing staff, including LVNs and CNAs, were not consistently aware of or trained on specific interventions to prevent further incidents, and several staff members reported not being informed of the resident's behaviors or the necessary preventive measures. The resident in question had a history of severe cognitive impairment, mild depression, and diagnoses including dementia and adjustment disorder with anxiety. Multiple documented incidents occurred in which the resident touched female residents inappropriately, often targeting those with poor cognition who could not advocate for themselves. Staff responses to these incidents varied, with some staff intervening immediately and others unaware of the resident's behavioral history or required interventions. The care plan was only sporadically updated, and interventions such as 1:1 supervision were inconsistently implemented or communicated among staff. Interviews with staff revealed gaps in communication, training, and care plan updates following each incident. Some staff were unaware of the resident's behavioral risks until after witnessing an incident, and others did not review the care plan or receive specific in-services related to the resident's behaviors. The lack of a coordinated, updated care plan and insufficient staff awareness placed other residents at risk of not having their behavioral needs met, potentially leading to further abuse and emotional distress.