Failure to Protect Cognitively Impaired Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents who were found engaged in sexual activity without staff knowledge. Both residents were cognitively impaired and lacked the ability to consent. The facility's policy on abuse prevention and capacity to consent clearly states that residents have the right to be free from abuse, including sexual abuse, and that consent is not valid if a resident lacks the capacity to consent. Despite this, the incident occurred, indicating a failure in monitoring and protecting the residents. Resident #1, diagnosed with dementia, depression, and altered mental status, was documented as severely cognitively impaired. Their care plan noted a risk for mood and behavior problems, and they had a history of wandering and making inappropriate sexual comments. On the day of the incident, Resident #1 was found in Resident #2's room, engaged in a sexual encounter. Staff intervention was delayed as the incident was only discovered when a Certified Nurse Aide entered the room. The resident's cognitive impairment and history of disrobing and confusion about other residents being their spouse were known to the staff, yet adequate supervision was not provided. Resident #2, with diagnoses including Wernicke's encephalopathy and vascular dementia, was also severely cognitively impaired. Their care plan noted behavior problems, including disrobing and being not always redirectable. The incident was reported to law enforcement, but the facility did not receive any feedback. Interviews with staff and family members revealed that both residents lacked the capacity to consent, yet the facility's investigation concluded the encounter was consensual. This discrepancy highlights a significant oversight in assessing and ensuring the residents' safety and protection from abuse.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away. a. Resident #2 had a room/floor change after the incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. A psychosocial evaluation has been completed by social work and resident does not even recall the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences, etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed and found to be appropriate. a. A monthly “relationship meeting” will be held to include Administrator, DON, Social Work, and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor “relationship meeting.” c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification, and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI, the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan.