F0656

D

Failure to Care Plan Resident’s Allegation of Consensual Relationship With Staff

Tyler, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables addressing a resident’s allegation of a consensual sexual relationship with a staff member and her related preferences. The resident was an older female with diagnoses including generalized anxiety disorder, chronic atrial fibrillation, osteoarthritis, and dementia without behaviors. A quarterly MDS showed she had adequate hearing, clear speech, intact cognition with a BIMS score of 15, and dependence on staff for transfers and bed mobility. Her care plan, dated 6/20/25, addressed self-care deficits related to osteoarthritis and indicated a two-person assist for bed mobility and turning, and that she took antianxiety medication. An intervention stating "I prefer female staff only" was present in the ADL care plan but was not initiated until 3/24/26.

A Provider Incident Report dated 3/7/26 documented that the resident alleged she had consensual relations with a caregiver. The resident was offered transfer to a hospital for evaluation but refused. An internal assessment by a licensed nurse found no trauma, no injury, and no emotional effect, but noted increased confusion compared to baseline. The resident’s physician evaluated her in person. The PIR narrative stated that interviews supported that the resident had been fixated on the accused staff member and frequently requested that he perform her care, and the facility ultimately determined the alleged abuse did not occur. During surveyor interview and observation, the resident described being in love with the CNA, reported having consensual sex with him, gave inconsistent details about the timing and presence of her roommate, and expressed that she felt safe and was not afraid of anyone. She also stated she did not plan to have sex with him again because she did not want either of them to get into trouble.

Multiple staff interviews confirmed that the allegation and the resident’s fixation on the CNA were known to facility staff but were not incorporated into the care plan. LVN A described the resident as sometimes confused, telling stories that did not happen, and said the resident was very fond of and obsessed with the CNA. The CNA denied any romantic or sexual relationship, reported that the resident had been calling him by a nickname combined with her last name, and stated he had been suspended during the investigation and later returned to work. The MDS nurse responsible for the resident’s care planning (MDS E) acknowledged she did not add the allegation or related issues to the care plan and stated she did not know how to word it, despite recognizing that everything about a resident should be care planned so staff know what is going on.

Other nursing leadership and staff also confirmed the omission. MDS C stated that the allegation should have been care planned because the care plan tells the story of the resident and would help nurses and CNAs understand and manage the situation as a behavior. LVN D reviewed the care plan and confirmed there was no entry addressing the accusation or incident with the CNA and stated it should have been on the care plan. The DON acknowledged that the resident was obsessed with the CNA, that the care plan did not address the allegation, and that the preference for female staff was only added on 3/24/26. The ADON stated the resident was very confused at times, had a UTI when she made the allegation, and should have been care planned for claiming a consensual relationship with staff, including the fact that the staff member had been moved to a different hall. The administrator also acknowledged that the allegation might have needed to be care planned. Despite the facility’s written care plan policy requiring comprehensive care plans with measurable objectives that are updated with significant changes and as needed, the resident’s care plan was not updated to reflect her allegation, her fixation on the staff member, or the resulting care needs and staff assignment changes, leading to the cited deficiency.