Failure to Provide Adequate Supervision for Resident with Behavioral Disturbances
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a history of behavioral disturbances, including inappropriate sexual behaviors. The resident, who was moderately cognitively impaired and diagnosed with dementia, bipolar disorder, and Alzheimer's disease, exhibited escalating inappropriate behaviors over a documented period. Despite an increase in medication dosage and multiple psychiatric evaluations, there was no documentation or implementation of increased supervision or monitoring for this resident. Staff interviews confirmed awareness of the resident's behaviors but revealed that no additional monitoring measures were put in place. An incident occurred in which the resident attempted to touch another resident, who was severely cognitively impaired and unable to protect herself, inappropriately. Staff intervened immediately during the incident, but records and interviews indicated that the facility had not taken proactive steps to prevent such events by increasing supervision. The Director of Nursing and other staff acknowledged the lack of documentation and implementation of increased monitoring, despite the resident's ongoing behavioral issues.