Failure to Implement Abuse Prevention Interventions for Resident with Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to implement care planned interventions to reduce the risk of abuse for a resident with a known history of inappropriate sexual behavior toward female residents. The resident, who had diagnoses including adjustment disorder with depressed mood, vascular dementia, and muscle weakness, was identified in his care plan as having poor impulse control and a pattern of inappropriately touching female residents. The care plan specified the use of a motion sensor, floor alarms, and one-to-one staff supervision in common areas to ensure the safety of other residents. Despite these interventions being documented, staff interviews and observations revealed that the motion sensor in the resident's room was not activated, the floor mat was not positioned correctly, and staff were not consistently providing the required supervision. On one occasion, a nursing assistant observed the resident reaching toward a female resident's breast, and staff acknowledged that he was known to be "grabby" and required close monitoring. Multiple staff interviews confirmed that the alarms intended to alert staff to the resident's movements were either not functioning or not in use, and the resident was able to ambulate independently without adequate supervision. Facility policy prohibits all forms of abuse, including sexual abuse, and requires monitoring to protect residents, but these measures were not effectively implemented for this resident.