F0740

E

Failure to Monitor and Individualize Care for Sexually Focused Behaviors in Cognitively Impaired Residents

Dunkirk, Indiana Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and develop individualized interventions for cognitively impaired residents who exhibited sexually focused or intimate behaviors. Five residents with dementia or significant cognitive impairment had either documented sexually focused behaviors, hypersexuality, or intimate relationships with other residents, yet their behavior monitoring and care plans did not include specific assessments, monitoring, or individualized interventions for sexual or intimate behaviors. Instead, behavior monitoring orders and tools focused on depression, anxiety, delusions, or general boundary issues, and there was no structured assessment for sexual behaviors in use at the facility.

One resident with moderate cognitive impairment and dementia (Resident B) had behavior monitoring ordered for depression-related symptoms and a care plan for impaired cognition and poor safety awareness, but no monitoring or individualized interventions for intimate or sexually focused behaviors. Social services documented that she sought companionship with a male resident, ate meals with him, and sat in the lounge with him, with her representatives agreeing to the relationship and the facility stating it would continue to monitor. Subsequently, staff observed her performing oral sex on a male resident in her room, after which staff intervened and removed the male resident. Prior to this event, her record lacked behavior monitoring or care plan interventions specifically addressing intimate or sexual behaviors.

Another resident with severe cognitive impairment and delusional disorder (Resident C) had a history of inappropriate personal boundaries, including touching others’ arms and legs, and was treated with medroxyprogesterone for hypersexuality with multiple dose adjustments and a failed gradual dose reduction. His resolved care plan for inappropriate boundaries included general boundary-setting strategies, and a current care plan acknowledged his companionship with female peers and allowed affectionate acts such as hand holding and putting his arm around them. However, his clinical record did not include monitoring tools or individualized interventions specifically targeting intimate or sexual behaviors. Nursing and social service notes documented increased friendliness and physical contact with female residents, agitation when redirected, and an incident where he was found in a female resident’s room receiving oral sex, but behavior monitoring tools reflected only irritability, anxiety, and searching for family, not sexual behaviors.

Residents D, E, and F, all with dementia and varying levels of cognitive impairment, had prior care plans for inappropriate personal boundaries that were later resolved and replaced with care plans describing mutual companionship with male peers, including hand holding and arm-around contact. These care plans emphasized acknowledging the need for connection, assessing understanding and ability to refuse, encouraging appropriate touch, offering privacy, and psychosocial visits, but did not include individualized monitoring or interventions specifically for sexually focused behaviors. Resident E exhibited verbally explicit sexual comments toward CNAs, including references to genital areas and suggesting sexual acts involving staff and another male resident, yet her behavior monitoring orders and tools addressed only depression and did not capture or target sexualized behaviors. Resident F’s record showed a long-standing close relationship with a male resident, family awareness of his frequent touching of her hands and legs, and discussion of possible environmental interventions, but her behavior monitoring focused on anxiety and searching for her daughter, with no documented monitoring or individualized interventions for intimate or sexual behaviors. The Social Service Director confirmed that the facility did not have a sexual behavior assessment, that behavior tools used by CNAs did not include sexual behaviors for these residents, and that decisions about resolving or framing care plans were influenced by discussions with the Ombudsman about residents’ rights rather than by structured behavioral health assessment and monitoring.

Overall, the facility’s behavior management process, as described in policy and interviews, required nursing to monitor target behaviors daily and social services to maintain a list of residents with behaviors and assist with behavior care plans. However, for these five residents with documented sexually focused behaviors, hypersexuality, or intimate relationships, the facility did not implement behavior monitoring specific to sexual behaviors, did not develop individualized behavioral health interventions addressing those behaviors, and did not use a formal assessment tool for sexual behaviors. Behavior sheets and monitoring focused on other symptoms such as depression, anxiety, irritability, and confusion, leaving sexually focused behaviors unmonitored and without individualized, documented interventions in the clinical record.