Failure to Notify Psychologist of Repeated Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to notify the psychologist regarding a resident who exhibited repeated inappropriate behaviors, including touching other residents and staff without consent. Despite extensive documentation of these behaviors in the resident's care plan and behavior summaries, which included hundreds of episodes of intense staring, standing too close, intrusiveness, masturbating in public, and inappropriate touching throughout the year, the psychologist was not informed of the severity or frequency of these incidents. The psychologist was also unaware of specific boundary violations, such as the resident attempting to kiss a staff member and entering shared bathrooms while occupied by other residents. The resident in question had a diagnosis of paranoid schizophrenia and was under conservatorship, with a documented history of poor boundaries and inappropriate social behaviors. The care plan included interventions such as encouraging behavioral health consultation and 1:1 counseling, but there was no evidence that the psychologist was kept informed of ongoing or escalating behaviors. Staff interviews confirmed that the resident's inappropriate touching and boundary issues were longstanding and required frequent redirection, but these actions were not effectively communicated to the psychologist for further intervention or adjustment of the treatment plan. Another resident, who was also diagnosed with paranoid schizophrenia and under conservatorship, reported psychological stress and emotional distress after being inappropriately touched by the first resident. This incident led to a physical altercation between the two residents. Staff and other residents corroborated the ongoing issues with the resident's intrusive behaviors. Facility policy required identification and intervention for residents with disruptive behaviors, but the lack of communication with the psychologist represented a failure to provide appropriate treatment and services for residents with mental disorders or psychosocial adjustment difficulties.