Failure to Prevent Transmission of Sexually Transmitted Infections Among Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in preventing the transmission of sexually transmitted infections (STIs) among residents. Three residents, all under conservatorship and lacking capacity to make their own decisions, engaged in unprotected sexual activity with each other. One resident with a confirmed diagnosis of a sexually transmitted virus had unprotected sex with another resident, who subsequently had unprotected sex with a third resident. Documentation showed that these interactions occurred on multiple occasions, and staff were aware of the sexual activities but did not implement adequate precautions to prevent STI transmission. Medical records indicated that the residents involved had significant mental health diagnoses, including schizophrenia and schizoaffective disorder, and were considered gravely disabled, requiring conservatorship for placement and decision-making. Despite these vulnerabilities, the facility's staff allowed residents to engage in sexual activity during designated free time without ensuring the use of condoms or verifying consent capacity. Staff interviews revealed a lack of knowledge and procedures regarding monitoring or promoting safe sex practices among residents, and there was no evidence of consistent implementation of infection control measures specific to sexual activity. The facility's own infection prevention and control policy referenced adherence to CDC guidelines, which recommend condom use to prevent the spread of HIV and other STIs. However, interviews with staff, including the infection preventionist, DON, and counselors, demonstrated that the facility did not have effective systems in place to ensure these guidelines were followed. The failure to implement appropriate precautions and monitor sexual activity among residents with known or suspected STIs resulted in a deficiency in the facility's infection prevention and control program.