Failure to Implement Interventions for Intimate Behaviors in Residents with Dementia
Penalty
Summary
The facility failed to implement appropriate interventions for two residents with dementia who were observed engaging in intimate behaviors, including kissing and holding hands, in the memory care unit's common area. Staff, including a CNA and an RN, were aware of the behaviors but were either unsure of the care plan interventions or unable to intervene effectively. The residents, both diagnosed with Alzheimer's disease, dementia, and other mental health conditions, were severely impaired in daily decision-making and had a history of wandering that intruded on the privacy of others. Despite being care planned for behaviors, staff could not identify or implement specific interventions during the observed incidents. During the observation period, the two residents continued to hold hands and enter their shared bedroom unsupervised with the door shut for at least 25 minutes, without staff intervention. The Memory Care Coordinator and other staff expressed uncertainty about how to address the situation, noting that this specific behavior had not been previously observed. Additionally, the facility lacked a dementia care policy, and there was confusion among staff regarding access to care plans and the appropriate use of dementia care training to manage such behaviors.