- Date
- 10/29/2023
- Report number
- OR0004785700
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to address resident's behavior
- Result
- Substantiated
- Findings
- Staff 1stated Resident 3 had exhibited sexually aggressive behaviors with another resident, but that resident had since moved out of the facility. S/he also stated that Resident 3 had been physically and verbally combative with staff and attempted to grab a female staff member by the neck. S/he stated the interventions the facility attempted for Resident 3's behaviors were to monitor and provide frequent checks. An incident report, dated October 29, 2023, indicated Resident 3 was found in a female resident's room near the female resident's bed. Resident 3's Temporary Service Plans indicated February 11, 2024 : "No female staff alone in residents’ room"; November 4, 2023 : "Make sure to be completing 15-minute checklist on resident. Getting more aggressive with staff. Keep away from female resident"; and October 31, 2023 : "Resident is to have 100% eyes on, and to be frequently checked on." Resident 3's service plan, dated January 18, 2024, did not include information regarding h/h aggressive behaviors with staff or residents, or interventions for staff to implement in the event Resident 3 became aggressive. A review of facility documentation for Resident 3's "15-minute safety checks" were incomplete and frequently un-dated. A site visit on February 13, 2024, and February 14, 2024, confirmed the facility failed to develop and implement a service plan that was reflective of resident needs for resident (# 3).