The first incident happened in the early morning as residents gathered in the activities room.

A Kahala Nui staff member caught a 94-year-old, wheelchair-bound man fondling another man and kissing his legs. The 94-year-old, who was cognitively and visually impaired, was told his behavior was inappropriate and quickly taken to his room.

It wasn't supposed to happen again.

But over the next two months in 2007, the man was able to fondle or kiss four other residents — some defenseless because of medical conditions — at Kahala Nui's Hi'olani Care Center, according to state records. In 15 other instances, staff members at the upscale nursing home intervened just before he could inappropriately touch the residents.

The problem went away only after the man was transferred to another facility.

The 2007 case underscores the difficulties long-term-care facilities have in dealing with inappropriate sexual conduct involving frail seniors.

But it also raises questions about how adequately Hawai'i institutions respond when allegations of such incidents happen.

Those very questions have been raised in the criminal case against a former Kahala Nui certified nurse aide, who pleaded guilty to sexually assaulting four elderly women when he worked there last year.

Mark Genetiano is scheduled to be sentenced today in Circuit Court on six counts of third-degree sexual assault. Over a two-month period, court documents say, Genetiano fondled the four nursing home residents, all suffering from dementia, by touching their breasts. The incidents were witnessed by co-workers.

Three colleagues reported that Genetiano pinched the patients' private parts while the women were changing clothes or in the bathroom, according to a police affidavit. The coworkers said the women tried to fend off his advances by waving their arms and yelling at him to stop, but Genetiano laughed at them, the affidavit said.

KAHALA NUI

A relative of one of the women has questioned whether Kahala Nui took proper precautions after the first incident was witnessed last April.

When allegations of abuse by a caregiver first surface, an institution is supposed to place the worker on leave or in a non-caregiving job to prevent additional resident contact while the allegations are investigated.

If the appropriate steps were taken, the relative said, how was Genetiano able to assault three other women — two more than once — over the next two months?

"What did Kahala Nui do to protect my sister?" asked the sibling, who The Advertiser isn't naming to preserve her sister's confidentiality. The newspaper doesn't identify victims in sex assault cases.

Genetiano's attorney declined comment.

Kahala Nui, in a statement issued before Genetiano pleaded guilty, said it took action immediately after learning of the incidents.

"As soon as it was discovered that a Hi'olani employee had potentially committed inappropriate actions that violate our zero-tolerance policy, the individual was relieved of his duties," then-Hi'olani administrator Sue Radcliffe said in the November statement. She added that the incidents were reported immediately to state regulators, Adult Protective Services and police.

In the 2007 case, Kahala Nui was not sanctioned even though regulators cited it for multiple violations, including failing to take reasonable precautions to protect residents, failing to thoroughly investigate some of the incidents and failing to report them promptly to the state.

After one incident in which the elderly man was seen attempting to touch another man, a staff member told the 94-year-old that sexually inappropriate behavior was not allowed. The elder resident, according to state records, yelled back: "I hate you b___h! I love him & he needs me!"

FILED AS 'ACCIDENTS'

In defending its actions, Kahala Nui told regulators it didn't report the incidents because it considered them accidents, not abuse, given that the man didn't intend to harm the others. After one fondling incident, he apologized, acknowledged his behavior was wrong and told staff he was trying to help the other man sleep. Regulators agreed to review the incidents as "accidents."

Kahala Nui also told the inspectors it took measures to closely monitor the man, including using body alarms, to prevent additional incidents.

"Even with the best and most stringent policies and procedures in place, you can't always control the actions of individuals," Radcliffe, who has since left Kahala Nui, said in her statement to The Advertiser. "What you can do, and what we do, is to train our workers to be vigilant, monitor for any mistreatment and take immediate corrective measures when it happens."

Regulators learned of the touching incidents in early 2008 only after discovering a reference in the file of a man who had been fondled by the 94-year-old. Regulators were reviewing files as part of Kahala Nui's annual inspection.

The institution made changes to its policy dealing with resident abuse in response to the inspection.

SANCTIONS AVOIDED

Regulations are strict about reporting and investigating allegations. But if institutions aren't sanctioned when they fall short of what is required, that sends the wrong message, critics say.

"These are all serious problems," said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy in Washington, D.C. "There need to be consequences."

Yet when Hilo Medical Center in 2008 failed to thoroughly investigate allegations of resident abuse by staff in several cases, it suffered no sanctions, according to state and federal records.

The alleged perpetrators were permitted to continue working with residents for days before being placed on administrative leave, according to the inspection report from June of that year.

A Hilo Medical administrator acknowledged that the facility's nurse managers were "all bad at conducting investigations," the report said. The same problem was identified by regulators the previous year, though Hilo Medical received no sanction then, either.

Likewise, Kahuku Hospital escaped sanctions in 2006 when inspectors discovered that a certified nurse aide under investigation for allegedly sexually abusing a resident was still working as a caregiver a week after the resident's family reported the allegation. Once regulators questioned the situation, the institution put the worker in a non-caregiving job and revised its procedures for abuse investigations.

There have been exceptions regarding sanctions.

Maluhia Hospital was fined $6,500 in 2008 for failing to take adequate precautions after a nursing home resident alleged that she was raped by a male CNA.

Eight other workers were aware of the allegation, yet none of them immediately reported the accusation to supervisors, as was required, according to the inspection report detailing the incident. The man continued to work in the same unit where the woman lived for about two weeks until she confided in a volunteer that she was raped a second time by the same CNA, the report said.

The volunteer alerted administrators, who immediately placed the worker in a desk job, launched an investigation and notified police.

Police were unable to substantiate the allegations.

Wahiawā General Hospital also was fined $4,550 in 2005 for allowing a CNA who was the focus of an abuse investigation to return to work before the inquiry was completed and even before the worker was questioned about the incident. The CNA subsequently was fired for providing substandard care, the records show.