F0600

G

Failure to Protect Residents From Sexual Abuse and to Implement 15-Minute Safety Checks

Malone, New York Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse, specifically sexual abuse and resident-to-resident aggression, and to implement and follow behavior care plans and safety interventions such as 15‑minute checks. One resident with Alzheimer’s disease, paralysis on one side, and aphasia had a care plan noting combative and resistant behaviors, weepiness, and attempts to self‑transfer, with goals that they would not be a victim or aggressor and interventions to monitor behaviors and escalations. Another resident with Parkinson’s disease, dementia with anxiety, and heart disease had a behavior care plan documenting a tendency to be sexually inappropriate, to wander, and to stay awake at night. The care plan for this resident initially focused on inviting them to activities, assessing for behaviors, and monitoring cognitive status, and was later updated to include diversion, 1:1 supervision, television, and 15‑minute checks. Despite this, between two specified dates there were 26 nursing notes documenting this resident’s sexually inappropriate comments, gestures, propositions, and physical contact with staff, including grabbing a staff member’s breast, without corresponding updates to the behavior care plan to add interventions to reduce sexually inappropriate behaviors or to protect other residents and staff.

Physician notes over time documented that the sexually inappropriate behaviors continued daily, with staff reporting increased sexually inappropriate comments and attempts at touching staff. The notes described multiple medication adjustments in response to ongoing sexual disinhibition, agitation, anxiety, hallucinations, and mood swings, and family concerns about the resident’s behavior. A prior incident was documented in which this resident was found in another resident’s room, in their wheelchair next to the sleeping resident’s bed, appearing to watch them sleep, and insisting that the sleeping resident was their spouse. Subsequent nursing documentation described the resident intrusively wandering into other rooms, stating other residents were their spouse, asking staff if they were married, and being difficult to redirect. Staff interviews indicated that 15‑minute checks were used for behaviors and resident‑to‑resident altercations, that all nursing staff were responsible for performing these checks, and that there was little or no specific training on managing sexually inappropriate resident behaviors beyond general dementia training and diversion tactics.

The deficiency culminated in an incident where the cognitively impaired resident with Alzheimer’s disease was found in their room with the sexually disinhibited resident. A family member entered the room and found the second resident lying on their side in the first resident’s bed with their pants and brief pulled down to their knees, while the first resident was in a t‑shirt and intact brief, with their left breast exposed according to witness statements. The first resident was crying and shaking and unable to communicate what had happened due to dementia. Facility documentation and hospital records indicated no penetration and no immediate physical injury, though later notes described small bruises on the resident’s leg and thigh of uncertain origin. Observation sheets showed that the sexually disinhibited resident was documented as being in their own room on 15‑minute checks during the time of the incident, despite being found in another resident’s bed. Interviews with the DON and other staff acknowledged that 15‑minute checks had failed to prevent the resident from entering other residents’ rooms and that staff were not able to keep residents safe under the existing interventions.

A separate but related deficiency involved another resident with Alzheimer’s disease, major depressive disorder, and severe cognitive impairment, who had a behavior care plan documenting wandering, verbally and physically abusive behavior, intrusive wandering, exit‑seeking, and aggressive behaviors such as kicking, hitting, abusive language, threatening behavior, resisting care, and striking or shoving other residents. The care plan included diversion activities and repeated use of 15‑minute checks after multiple incidents, including unsafe wandering, striking a resident on the head, shoving a resident to the floor, kicking a resident, and hitting a resident in the chest and face. On one date, a care plan note documented that this resident was agitated, pushed a staff member, could not be redirected or calmed, and was given intramuscular Haldol and placed on 15‑minute checks. However, on a later date, surveyor observations and record review showed that although the resident was listed on the unit 15‑minute check list, the check sheets were not signed from 11:45 a.m. through 12:30 p.m., and staff reported they were assisting with lunch and did not complete or document the checks during that period.

During that same timeframe, the resident with aggressive behaviors was observed in their room watching television, and later was found wandering into another resident’s room and had to be redirected back to their own room. An LPN subsequently signed all residents’ 15‑minute check sheets while speaking with the surveyor and stated they documented that the aggressive resident was wandering for all the missing time slots based on finding them in another resident’s room at 1:04 p.m. Staff interviews revealed confusion about why this resident was on 15‑minute checks, with one RN stating there was no note explaining the reason and that staff had the checks stopped when they could not determine the rationale. The DON stated that 15‑minute checks were typically used for 72 hours and then reassessed, and that the need for checks should be reflected in the care plan, care cards, electronic notes, and shift‑to‑shift communication, with all staff responsible for performing and documenting the checks. The failure to consistently implement and document the ordered 15‑minute checks for this resident with a history of aggressive and abusive behaviors placed other residents at risk for abuse.