Failure to Develop and Implement Care Plan for Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing sexually inappropriate behaviors for a resident with a known history of such behaviors. Despite documented incidents of sexually inappropriate comments and actions, including a prior event where the resident asked to see a staff member's breasts and a psychiatric evaluation noting sexually impulsive behavior, the care plan was not updated to include individualized interventions, monitoring instructions, or staff guidance. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status score of 6 and psychiatric notes describing poor judgment, impaired decision-making, and confusion. On the day of the incident, the resident inappropriately touched the breasts of two female residents in the day room. After the first incident was witnessed by a staff member, the resident was taken to his room but left unsupervised. Another staff member, unaware of the incident, assisted the resident back to the day room, where a second incident occurred. Both female residents involved had severe cognitive impairment and required staff assessment for mental status. The facility had prior knowledge of the resident's sexually inappropriate behaviors but did not implement immediate supervision or restrictions to protect other residents. Interviews with facility staff confirmed that the care plan was not updated until after the incidents occurred, despite escalating behaviors and psychiatric recommendations. The lack of timely and effective care planning and supervision resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported, assigned to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse, Identifying Sexual Abuse, and Capacity to Consent by Staff Development Nurse and Administrator. Train all staff that if staff witnesses abuse, the perpetrator or initiator cannot remain in contact with other residents and must be taken to a supervisor or another employee must remain with them until a decision is made. Do not allow staff to work until in-serviced.
- Discipline and educate LPN on 1-1 supervision when there is an abuse allegation.
- Educate CNA on proper undergarment placement for Resident.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Residents.
- Initiate hourly checks on Residents.
- Send referrals to multiple Geri-psych units and other facilities for Resident.
- Assign 1-1 observation of Resident to the scheduled Certified Nursing Assistant (CNA) and use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.