Failure to Prevent Resident Sexual Exposure
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing effective interventions to prevent a resident from exposing his genital area to others. Despite being aware of the resident's ongoing behavior of inappropriate nudity and sexual comments, staff interventions were limited to placing a blanket on his lap, which was repeatedly reported as ineffective. Multiple staff members acknowledged that the blanket did not consistently cover the resident, and there were no new or alternative interventions put in place after the incident where the resident exposed himself in a common area in proximity to two other residents, both of whom had severe cognitive impairment. The resident with a history of inappropriate display of nudity and sexual comments had diagnoses including Alzheimer's dementia, enlarged prostate, stroke, overactive bladder, urinary retention, and cognitive communication deficit. The care plan had not been updated with effective strategies since the last modification several months prior to the incident. Staff interviews confirmed awareness of the behavior and the ineffectiveness of current interventions, yet no additional measures were implemented to prevent recurrence, resulting in continued exposure of other vulnerable residents to inappropriate conduct.