Failure to Update Care Plan for Resident at Risk of Exploitation
Penalty
Summary
The facility failed to update the care plan for a resident to reflect their risk for exploitation, despite evidence from assessments and staff observations indicating this risk. The resident in question had a BIMS score of 8, indicating moderately impaired cognition, and medical diagnoses including metabolic encephalopathy, non-Alzheimer's dementia, depression, and adjustment disorder. The care plan had previously addressed the resident's tendency to show affection to others, but did not address the risk of exploitation or the resident's inability to provide informed sexual consent. An incident occurred in which the resident was found unclothed in another resident's bed, with both residents unclothed and kissing. Staff intervened, performed a head-to-toe assessment, and separated the residents. The facility completed a verbal informed sexual consent assessment, which revealed that the resident did not demonstrate the ability to identify harmful situations or avoid exploitation. However, the care plan was not updated to reflect these findings or the resident's inability to provide informed consent. Interviews with the Administrator, Social Services, and the DON confirmed that the care plan should have been updated to reflect the resident's risk for exploitation and inability to give informed consent, but this was not done. The facility's policy requires that care plans include measurable objectives and interventions based on comprehensive assessments, but this requirement was not met in this case.