Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was not protected from sexual abuse by another resident. The incident involved two male residents, both diagnosed with dementia and significant cognitive deficits. One resident, who was dependent for most activities of daily living and unable to protect himself, was found in his bed with his brief open while his roommate was observed by staff to be fondling his genitals. The cognitively impaired resident was asleep and unable to respond or defend himself during the incident. Staff interviews and written statements confirmed that the inappropriate contact was directly observed by a nurse aide and a medication aide, who intervened to stop the behavior. Prior to this event, there was no documented history or care plan indication that the resident who initiated the contact had exhibited sexually inappropriate behaviors. Both residents had been roommates for approximately two weeks, and staff had not reported any prior concerns regarding inappropriate touching or aggression between them. The incident was discovered during routine rounds, and staff responded by separating the residents and assessing for injuries, of which none were found. The resident who was abused was severely cognitively impaired, unable to recall the incident, and had a history of behavioral disturbances but no recent behaviors. The other resident also had significant cognitive and intellectual deficits and was not aware of his actions. The family of the abused resident expressed that he would have been unable to defend himself and would have been upset by such an incident. The facility's failure to anticipate or prevent this event, despite both residents' vulnerabilities, resulted in a violation of the requirement to protect residents from all forms of abuse, including sexual abuse.