F0740

E

Failure to Assess, Document, and Care Plan Behavioral Health and Sexual Expression Needs

Indianapolis, Indiana Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely develop and update behavior care plans and to document behaviors on tracking logs for three residents with significant behavioral health needs. For one resident with paranoid schizophrenia and bipolar disorder, the record showed repeated delusional reports and sexually focused interactions involving another male resident. She alleged inappropriate touching and assault by the male resident, but staff found the male resident in his own room and a head‑to‑toe assessment revealed no injury. Subsequent documentation described her as having chronic fluctuating psychosis, delusions, hallucinations, and poor judgment and insight. Despite a capacity-to-consent assessment indicating she could describe sexual activity and related risks, there was no physician assessment of her cognitive ability and insight to engage in a sexual relationship, and later physician documentation concluded she did not have decision‑making capacity to consent to sexual activity. Her care plan did not reflect that she was unable to consent to sexual activity, did not address redirection of others from her room, and did not address her behavior of identifying herself as different people.

The male resident involved had vascular dementia with behavioral disturbance, schizophrenia, and chronic hepatitis C. He had existing care plans for impaired cognition and intrusive wandering, including redirection from other residents’ rooms. Nursing notes documented that he was found in the female resident’s room exposing himself, and later again found in her room, calm and fully clothed, and redirected. A capacity-to-consent assessment indicated he could describe sexual activity, avoid exploitation, and understood physical, emotional, and health consequences, but there was no physician assessment of his cognitive ability to consent to a sexual relationship. A physician progress note later documented that he wished to engage in an intimate relationship with the female resident, that his mental capacity was impaired, and that he could not describe how he would prevent pregnancy or STDs. The physician did not approve sexual activity because the female resident lacked capacity, and noted the male resident’s own impaired capacity. Despite these findings and repeated room‑entry behaviors, there was no care plan indicating he was unable to consent to sexual activity and no behavior care plan addressing his ongoing attempts to enter the other resident’s room.

A third resident with metabolic encephalopathy, depression, anxiety, and cognitive communication deficits exhibited new exit‑seeking and escalating behavioral symptoms that were not incorporated into his care plans in a timely manner. Initially assessed as not an elopement risk, he attempted to leave the building, was redirected, and a provider note documented exit‑seeking behavior. Subsequent behavior notes described him pressing a keypad near an employee exit, cursing and refusing redirection, and later yelling, calling staff names, and throwing himself from his wheelchair to the floor in the dining room. An elopement evaluation was later updated to show a history of elopement and wandering with a score indicating elopement risk, and he called 911 stating he wanted to kill himself, leading to an emergency department visit for suicidal ideation. Despite these documented behaviors, there was no elopement care plan developed with interventions, and his behavior care plans were not updated with new interventions to address the exit‑seeking, agitation, and self‑injurious behaviors. The facility’s own behavioral health and sexual expression policies required assessment, IDT involvement, documentation of behaviors and triggers, and timely care plan development and revision, which were not carried out as described in the records and staff interviews.

Staff interviews further demonstrated gaps in communication and implementation of behavior management and sexual expression policies. CNAs reported being informally told around New Year’s to keep the two sexually involved residents out of each other’s rooms, but a QMA stated he had not been informed of this and observed the residents frequently visiting each other’s rooms. The social worker reported not being made aware that the female resident had videotaped the male resident exposing himself or that the male resident had exposed himself to her, even though the facility’s sexual expression policy required staff to notify social services and the DON when residents engaged in intimacy or sexual activity. The staff development coordinator acknowledged awareness of the videotaping incident and that the executive director had been informed, but could not recall any specific interventions set up for either resident beyond staff informally looking in on them. The social worker also confirmed that the female resident did not have a care plan addressing redirection of others from her room or guidance on private visits, and that behavior care plans were supposed to be developed by social services with the IDT using behavior notes and charting, which had not occurred in these cases.

Overall, the documented events show that for all three residents, the facility did not ensure that necessary behavioral health services were provided in a person‑centered, assessed, and care‑planned manner consistent with its own Behavioral Health Services and Sexual Expression of Residents policies. New and ongoing behaviors—including delusional reports, sexually focused interactions, exposure, intrusive room‑entry, exit‑seeking, agitation, verbal aggression, and self‑injurious behavior—were not consistently translated into updated behavior plans of care or specialized care plans (such as elopement or sexual consent status). Behavior tracking and communication to social services and the IDT were incomplete or delayed, and physician assessments regarding capacity to consent to sexual activity were either missing or not integrated into the care plans. These omissions and delays in assessment, documentation, and care planning constitute the behavioral health care and services deficiency identified by the surveyors.