Failure to Implement Individualized Interventions for Sexually Inappropriate Behaviors in Dementia Resident
Penalty
Summary
The facility failed to implement individualized interventions for a resident with dementia who exhibited sexually inappropriate behaviors towards female residents. One resident, diagnosed with vascular dementia and severe cognitive impairment, was documented on multiple occasions to have inappropriately touched female residents, including incidents where he placed his hand inside a female resident's shirt and touched her breast, and another where he touched a female resident's chest while returning from a smoke break. Despite these incidents, documentation in the clinical record was inconsistent, with gaps in recording the behaviors that prompted safety checks and a lack of clear communication to staff regarding the resident's history of sexually inappropriate actions. Interviews with staff revealed uncertainty and lack of awareness about the reasons for safety checks and the resident's behavioral history. Some staff members were unaware of the resident's sexually inappropriate behaviors, and the Kardex did not contain alerts or documentation about these behaviors. The care plan did include some interventions, such as supervision during smoke breaks and one-on-one supervision, but these were not consistently communicated or documented in a way that ensured all staff were informed and able to implement them effectively. Other residents reported feeling uncomfortable, upset, and fearful as a result of the inappropriate behaviors, and there was evidence that incidents were not always thoroughly investigated or followed up with the affected residents. The facility's dementia care policy required individualized care plans and ongoing monitoring of interventions, but the observed deficiencies indicated a failure to consistently identify, document, and address the resident's sexually inappropriate behaviors, as well as to protect other residents from further incidents.