F0744

D

Failure to Develop Dementia Care Plan Addressing Resident’s Sexual and Physical Engagement Needs

Hutchinson, Kansas Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement an adequate dementia-focused plan of care that identified and honored a resident’s desire for physical and sexual engagement, and to provide staff with clear direction on recognizing voluntary engagement and monitoring for negative outcomes. The resident had diagnoses including dementia, major depressive disorder, anxiety, and unspecified sexual dysfunction, and was documented as having severely impaired cognition, being inattentive, and having disorganized thinking. The resident was dependent on staff for most care and could not complete a BIMS interview. Early care plan entries focused on potential physical aggression related to dementia and included general behavioral interventions such as administering medications, analyzing triggers, anticipating needs, providing cues, and monitoring for danger to self or others, but did not address the resident’s expressed sexual desires or patterns of seeking male companionship.

Over time, the resident repeatedly demonstrated sexually focused and socially inappropriate behaviors that were documented in the EHR and behavior monitoring reports. Nursing notes and behavior logs described the resident transferring into other residents’ beds, attempting to disrobe in common areas, approaching male residents with sexually driven remarks, and being found in a male resident’s room with her pants down while the male resident touched her peri-area. Additional notes documented the resident verbally expressing that she wanted a man, being verbally inappropriate with sexually explicit language, attempting to expose her breasts to a male resident, and entering other residents’ rooms while looking for a man. Behavior monitoring reports showed a pattern of inappropriate behaviors, including entering other residents’ rooms and public sexual acts on multiple dates over several months. Despite this pattern, the care plan revisions that were eventually made focused on redirecting the resident, avoiding triggers, and offering diversions such as baby dolls, without a comprehensive dementia care plan that addressed her ongoing desire for physical engagement or guidance on distinguishing voluntary engagement from nonconsensual or unsafe situations.

Interviews with administrative staff and direct care staff further demonstrated gaps in the facility’s approach to dementia care related to sexuality and physical engagement. Administrative staff acknowledged that the resident had gravitated toward males since admission and had vocalized multiple past marriages, but also stated that there was very little social history available on admission and that the care plan interventions for sexually inappropriate behaviors were opened only after a specific incident and finalized later. Certified medication aides, CNAs, and a licensed nurse reported receiving general dementia training via online modules but were unsure or could not recall receiving specific training on managing sexual or intimate desires in elders with dementia. Staff described their responses as separating residents, using distraction, and notifying a nurse, and some were unaware of specific incidents of sexual or intimate interactions despite documented events. The facility’s Dementia Care policy did not address sexuality or intimate relationships in residents with dementia, and while the Behavioral Health Services Guideline mentioned inappropriate sexual behavior and the need to respect sexual behaviors between consenting, competent adults, it did not translate into a resident-specific dementia care plan that identified and honored this resident’s desire for physical engagement or provided clear direction on monitoring for potential negative outcomes.