Failure to Address and Monitor Hypersexual Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to provide necessary services to meet the psychosocial needs of a resident diagnosed with severe dementia and a history of hypersexual behaviors, resulting in resident-to-resident sexual abuse. The resident, who was a registered sexual offender with a BIMS score indicating severe cognitive impairment, exhibited sexually inappropriate behaviors as early as March, including kissing, touching, and wandering into other residents' rooms. Despite these behaviors being observed and reported by multiple staff members, the facility did not initiate a care plan addressing the potential for sexual inappropriateness until several months later. Behavior monitoring for the resident was limited and did not specifically include sexually inappropriate behaviors, focusing instead on general mood and adjustment issues. Documentation of behavior monitoring was infrequent, with only three recorded instances over approximately six months, and did not reflect the frequency or severity of the inappropriate behaviors described by staff. Additionally, the resident's known relationship with another resident was not care planned, and there was a lack of timely documentation regarding notification or acceptance of this relationship by responsible parties. Staff interviews revealed that the resident's sexually inappropriate behaviors were widely known among employees, with reports of daily incidents involving multiple residents, including those unable to communicate. Despite this, interventions and care planning were delayed, and there was insufficient monitoring and documentation of the resident's behaviors. The facility administrator confirmed these failures, acknowledging that the necessary services to address the resident's psychosocial needs were not provided, resulting in the occurrence of resident-to-resident sexual abuse.