Failure to Timely Develop Person-Centered Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s sexual behaviors despite multiple documented incidents. Facility policy dated 1/4/25 required comprehensive assessments, care planning, and care delivery to include collecting and analyzing information, choosing and initiating interventions, and then monitoring and adjusting interventions. The resident, who had diagnoses including parkinsonism, bipolar disorder, and anxiety disorder, had a BIMS score of 15 on the 10/26/25 MDS, indicating intact cognition. The clinical record showed that the resident exhibited sexual behaviors on 7/21/25, 7/23/25, 8/16/25, and 1/3/26. Despite these documented behaviors, the resident’s care plan addressing sexual activity and sexual expression was not initiated until 1/5/26. When it was initiated, the goal was for the resident to be safe during the stay and protected from unconsented sexual expression, with interventions including education to the resident/responsible party as needed, notifying family as needed for cognitively impaired residents, providing privacy if both residents were deemed capable of consenting, and staff providing comfort, reassurance, support, and risk assessment. During an interview on 1/14/2 at approximately 4:00 p.m., the Nursing Home Administrator and the DON confirmed that the facility failed to develop and implement comprehensive care plans to meet resident care needs for one of five residents, in violation of 28 Pa. Code 211.11(d) Resident Care Plan.
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