Failure to Provide Timely Behavioral Health Services for Escalating Sexual Behaviors
Penalty
Summary
The facility failed to provide timely behavioral health services for a resident with Alzheimer’s disease, dementia, and a mood disorder who had severe cognitive impairment but was independent with transfers and walking. A psychiatry consult in April 2025 documented no mood or behavioral disturbances in the prior 30 days, discontinued sertraline, and recommended no psychotropic medications at that time, but advised continued monitoring and documentation of mood and behavioral disturbances with descriptions and whether the behaviors were redirectable, with follow-up as needed. Beginning in July 2025, nursing progress notes documented multiple episodes of inappropriate and sexual behaviors, including an allegation that the resident exposed his genitals to a female resident and initiation of 15‑minute checks. Subsequent nursing notes from September 2025 through January 2026 recorded repeated inappropriate sexual gestures, spitting, yelling, cursing, difficulty with redirection, entering female residents’ rooms and looking at them in bed, rummaging through a roommate’s personal items and food, kissing a female resident, masturbating in an elevator, and being found behind a door kissing and attempting to pull his pants down. An event report on February 2, 2026, documented that the resident was found in a female resident’s room masturbating, with one hand on the other resident’s side and her gown pulled down to the knee, though her brief remained intact. The behavioral notes did not show that the primary physician was notified of these escalating inappropriate and sexual behaviors, and review of records from July 19, 2025, through January 31, 2026, showed the facility did not provide behavioral services during this period despite the multiple documented episodes, only obtaining psychiatric follow-up after the February 2, 2026 incident.
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