F0744

J

Failure to Provide Adequate Behavioral Health Services and Supervision for Residents With Dementia and Sexual Behaviors

Pleasantville, Ohio Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents with dementia and known histories of sexually inappropriate behaviors received adequate and effective behavioral health services, individualized interventions, monitoring, and supervision. One resident with moderately impaired cognition and a long history of sexually inappropriate behaviors had multiple documented incidents over several months, including oral sex with another resident, encouraging a male resident to rub her legs, kissing a male resident in her room, being observed with a male resident’s hands in her pants, repeatedly entering male residents’ rooms, and speaking in explicit sexual detail to her roommate. Her guardian repeatedly expressed concerns and requested increased safety measures, including a transfer to an all-female facility. The resident’s care plan included intermittent periods of one-to-one observation and every 15‑minute checks, but these heightened monitoring interventions were repeatedly started and then resolved, and the 15‑minute checks were discontinued in October without documented rationale or authorization from the psychiatric provider.

Another resident with severely impaired cognition and dementia also had a documented history of sexually inappropriate behaviors. His care plan identified sexually inappropriate behavior after an encounter with another resident and included interventions such as behavioral health services, medication management, and one-to-one observation if sexually inappropriate behavior occurred. He was prescribed cimetidine (Tagamet) off-label to reduce sexual desire. Nursing notes documented multiple episodes of him touching himself inappropriately in common areas and being redirected to his room, as well as reports from his sister about sexually inappropriate behaviors at his offsite day program and concerns about the effectiveness of his medication. Despite these ongoing behaviors and concerns, after his room was changed to a secured unit due to inappropriate touching of a female resident, there was no documented evidence of increased monitoring, reassessment, or new interventions between the time of the move and the subsequent incident.

The deficiency culminated when the resident with severely impaired cognition and the resident with moderately impaired cognition, both with known sexually inappropriate behaviors, were placed on the same secured unit without reassessment or revision of their behavioral health care plans related to monitoring and supervision. Direct care staff expressed concerns about moving the male resident with sexually inappropriate behaviors to a unit where residents were generally less cognitively aware and more vulnerable, but these concerns were either not communicated to management or not acted upon. No increased monitoring or individualized behavioral interventions were implemented for either resident after the room change. Several days later, staff discovered the two residents in the female resident’s bedroom with both residents partially undressed and engaged in sexual intercourse, confirming that the facility had not provided the necessary behavioral health services, individualized interventions, and supervision required by their conditions and histories.

The facility’s own policies on dementia care and behavior assessment required the interdisciplinary team to identify resident-centered care plans, evaluate behavioral symptoms for safety risk, monitor for worsening symptoms, and adjust interventions based on changes in behavior and needs. However, the residents’ ongoing sexually inappropriate behaviors, repeated incidents, guardian concerns, and changes in placement were not accompanied by consistent reassessment, documentation, or adjustment of monitoring and supervision. The psychiatric mental health nurse practitioner reported she was not informed of continued sexually inappropriate behaviors after the male resident’s room change and did not authorize discontinuation of the female resident’s 15‑minute checks, indicating a breakdown in communication and failure to follow established behavioral health protocols that contributed directly to the incident.

Removal Plan

• The DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were notified of the sexual incident with Resident #10; full body skin assessments were completed for Resident #05 and Resident #10.
• Resident #10's guardian was notified by the facility of the sexual incident with Resident #05; the facility requested permission to transfer Resident #10 out of the facility later that day.
• The facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.
• Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905.
• Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.
• Resident #10 was discharged to another facility.
• Resident #05 was discharged to another facility.
• MDS Nurse #273, ADON #339, and Wound Nurse #354 interviewed all residents with a BIMS score of 13 and above about inappropriate sexual encounters, reporting, and safety; all residents with a BIMS score of 12 and below had a skin assessment completed to identify any possible changes.
• MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.
• RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 educated all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents (including pre-admission IDT review for sexual behaviors; care planning for residents with dementia or cognitively intact residents with sexual inappropriate behaviors; psychiatric follow-up; immediate notification to nursing management and psychiatric team; immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe).
• ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify documentation of sexual behaviors; five residents (#60, #61, #63, #64, and #65) were placed on every 15-minute checks for inappropriate comments to staff; orders and notifications were completed; direct care staff would complete observations with management completing checks if changes were needed; IDT/psychiatric/physician would determine discontinuation; at-risk residents would be reviewed weekly with changes prompting team discussion and plan of action.
• MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.
• An ad hoc QAPI meeting was held to review the system change for sexually inappropriate residents and education provided to staff (including Medical Director, Activities Director, HRD, Social Services Assistant, Regional Nurse, MDS Nurse, Receptionist, Wound Nurse, and CQAN).
• The facility created an audit tool to be reviewed weekly at standard of care meetings with the IDT to ensure residents were identified and interventions were in place; residents with a diagnosis of sexual behavior or any sexual behavior identified would be audited weekly; the system change would continue ongoing.
• The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.
• The medical records for Residents #60, #61, #63, #64, and #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.
• Direct staff members were observed providing adequate surveillance for Residents #60, #61, #63, #64, and #65 with no issues noted.
• Interviews with RN #191, LPN #504, and CNA #141 verified staff were educated regarding dementia clinical protocol, resident routine checks, and behavioral assessment/intervention/monitoring, and were knowledgeable of residents requiring increased surveillance and the procedure for resident checks.