Failure to Implement Care Plan for Resident With Hypersexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions related to a resident’s known hypersexual behaviors. The resident was admitted with dementia, behavioral disturbances, psychotic and mood disturbances, and was later diagnosed with high-risk heterosexual behavior. The resident’s care plan, initiated on 01/05/2026, identified a focus on potential behaviors related to depression, dementia, and hypersexual behaviors, with a goal of no evidence of behavior problems. Interventions included anticipating and meeting needs, assisting with appropriate coping and interaction, encouraging appropriate expression of feelings, providing opportunities for positive interaction, intervening to protect the rights and safety of others, removing the resident from situations as needed, monitoring behavior episodes to determine underlying causes, and documenting behaviors and potential causes. Despite these identified interventions, staff interviews and record review showed that the care plan was not effectively implemented. A physician note documented that over a weekend, staff observed the resident attempting to touch a female resident, and the resident was described as non-verbal with a history of impulsive behaviors. A psychiatry note indicated ongoing behavioral concerns involving inappropriate gestures toward staff and other residents, with the resident demonstrating limited awareness of their behavior. A CNA reported witnessing an incident during breakfast tray pass where the resident was found in another resident’s darkened room, with that resident lying in a fetal position with their brief pulled down, while the resident had a clenched fist against the other resident’s vagina and their other hand on their exposed penis. The CNA separated the residents and removed the resident from the room. The same CNA also described a prior unreported inappropriate interaction between the same two residents in the dining room months earlier, where the other resident opened their legs and incontinence brief toward the resident, and the CNA redirected but did not report the incident. Multiple staff interviews revealed a lack of awareness and implementation of the care plan and the resident’s hypersexual diagnosis. The DON stated she had not read the treatment plan and was unaware of the hypersexual behavior diagnosis. An LPN who had cared for the resident did not know of the hypersexuality diagnosis or behaviors, although they knew the resident frequently masturbated in a shared room. A CNA assigned to one-to-one supervision for the resident reported not knowing what specific behaviors to watch for or the reason for the one-to-one assignment. Observation in the dining area showed the resident and the other involved resident seated in the same room without staff at their tables and without continuous one-to-one supervision for several minutes, until a CNA returned with a behavior monitoring form. The Nursing Home Administrator also reported being unaware of the resident’s hypersexual behavior diagnosis and not being concerned about behavioral issues, despite the facility’s policy requiring that qualified staff responsible for carrying out care plan interventions be notified of their roles and responsibilities.
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