Failure to Develop and Implement Care Plan for Resident Relationship
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the relationship between two residents, both of whom had intact cognition and court-appointed Conservators of Person (COP). One resident had a history of trauma and the other had a prior incident of allegedly inappropriate touching of a peer. Despite staff awareness of the ongoing friendship and frequent private visits between the two residents, there was no documentation in either resident's care plan addressing their relationship or providing guidance for staff on monitoring or managing their interactions. Multiple staff members, including nursing assistants, social workers, LPNs, and the administrator, confirmed knowledge of the residents' friendship and private visits, often with the door closed and without staff monitoring. Both residents' COPs were aware of the relationship, and one resident reported feeling uncomfortable after previously consenting to intimate contact. Facility policy required care plans to reflect resident preferences and needs, but no care plan interventions were documented to address the relationship, resulting in a deficiency.