Failure to Provide Appropriate Behavioral Health Management for a Resident With Sexualized Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with severe cognitive impairment and known behavioral issues. The resident had diagnoses including stroke, cognitive impairment of unknown etiology, and Parkinson’s disease, with a BIMS score of 2 indicating severe cognitive impairment. The MDS documented other behavioral symptoms not directed toward others occurring on one to three days, and the care plan identified a potential for behavioral problems due to cognitive impairment, including sexually inappropriate behavior toward staff. The care plan interventions included anticipating and meeting needs, monitoring behavior episodes to determine underlying causes, documenting behaviors and potential causes, and praising progress. The resident’s activity preferences indicated that reading materials, music, being around animals, doing favorite activities, and going outside for fresh air were important to them. Behavior documentation showed that the resident made numerous attempts to disrobe in the hallway and was later documented as exposing and manipulating his penis. Another resident reported being upset after observing this resident masturbating in a common area, and facility documentation acknowledged that the resident had advanced dementia and had been observed at the nurses’ station with displaced clothing due to confusion. During observation, the resident was seated at the nurses’ station in a reclining medical wheelchair next to a non-medical unit secretary, with no stimulation or diversional activities provided. Staff interviews confirmed that the resident frequently disrobed and manipulated his penis, that redirection efforts were not always successful, and that the resident could not be left alone in his room due to fall risk. The DON confirmed that the facility failed to ensure the resident received appropriate behavioral health management to maintain the highest practicable well-being.
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