Failure to Revise Care Plan After Resident’s Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive care plan to address a resident’s allegation of sexual abuse. The resident was an adult female with bipolar disorder, mild cognitive impairment, major depressive disorder, and anxiety, who was cognitively intact with a BIMS score of 15 and had no hallucinations or delusions documented on her MDS. Her care plan, initiated for psychotropic medication use related to depression and anxiety, included monitoring for side effects such as mania, hostility, rage, impulsive behavior, and hallucinations, with a goal for her to be free from cognitive/behavior impairment. However, after the resident made an allegation of sexual abuse by a staff member, the care plan was not updated to reflect this allegation or to address it as part of her individualized plan of care. Interviews with multiple staff confirmed that the care plan was not revised following the sexual abuse allegation. RN B stated she did not know why the care plan was not updated and indicated that the MDS Coordinator and management staff were responsible for care plans, while nurses implemented them. The MDS Coordinator acknowledged awareness of the sexual abuse incident and, after reviewing the resident’s care plan from late September through late January, confirmed it had not been updated to include the allegation and could not explain why. The ADON, DON, and Administrator each stated that management or the MDS Coordinator was responsible for developing and updating care plans and acknowledged that the resident’s care plan had not been updated, without being able to provide a reason. Facility policy on abuse required protection of residents’ health, welfare, and rights, prohibited sexual abuse, and required oversight and staff education to prevent abuse, but the care plan remained unchanged despite the reported allegation.
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