Failure to Ensure Safe Environment and Oversight for Residents Unable to Consent to Sexual Activity
Penalty
Summary
The facility failed to ensure a safe environment and adequate oversight for two residents who were unable to make their own decisions, resulting in one resident experiencing emotional distress and feeling unsafe. Both residents had significant mental health diagnoses, including schizoaffective disorder, anxiety disorder, paranoid schizophrenia, and bipolar disorder, and were under conservatorship, indicating they could not make their own medical decisions but could express their needs. Despite these limitations, the facility did not ensure that staff were aware of or monitored the sexual activities between the two residents. Staff interviews revealed inconsistent awareness and understanding of the residents' relationship and sexual activities. A Certified Nursing Assistant acknowledged the relationship and stated that residents had the privilege to have sex, but also indicated that staff should be alerted if residents were seen together in certain ways. However, a Registered Nurse was unaware of the sexual relationship and had not been informed by the residents or other staff. The Director of Nursing and the Administrator described general monitoring practices but did not demonstrate that specific oversight or interventions were in place for these two residents, who were known to lack decision-making capacity. Following the sexual encounter, one resident exhibited significant emotional and psychological distress, including panic, anxiety, increased pacing, new or worsened delusions or hallucinations, and expressed feeling unsafe and wanting to harm others. The resident was subsequently evaluated by a psychiatric crisis team and transferred to a hospital. The facility was notified by the hospital that the resident alleged her boyfriend was sexually and physically aggressive with her. The facility's investigation confirmed that staff were not fully aware of the sexual activities or the need for closer monitoring of these residents, as required by their conditions and care needs.