Failure to Revise Care Plan After Repeated Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with measurable objectives, time frames, and appropriate interventions for a resident with a history of sexually inappropriate behaviors. Despite multiple documented incidents where the resident engaged in inappropriate sexual contact or behaviors towards other residents, there was no evidence that the care plan was updated to address these behaviors or to implement interventions to prevent further incidents. The care plan remained unchanged after several events, including the resident being observed touching another resident inappropriately, standing outside other residents' rooms, and being found in a compromising position with another resident. The resident in question had diagnoses of cerebral infarction and vascular dementia, with assessments indicating varying levels of cognitive impairment and ambulatory status over time. Progress notes and staff interviews documented repeated incidents of inappropriate sexual behavior, including physical contact with other residents and attempts to enter other residents' rooms. Despite these documented behaviors, the care plan did not reflect any new strategies or interventions to address the resident's actions or to protect other residents from potential abuse. Staff interviews revealed that while some monitoring and reporting occurred, there was a lack of clear documentation or care plan updates specifying how the resident should be monitored or what interventions should be implemented. The responsibility for updating care plans was acknowledged by nursing leadership, but it was confirmed that the care plan for the resident was not revised following the incidents. This failure to update the care plan as required by facility policy and regulation resulted in a deficiency related to the prevention of abuse and the management of resident behaviors.