F0600

J

Failure to Protect Cognitively Impaired Residents from Sexual Abuse

Durham, North Carolina Survey Completed on 04-11-2025

Penalty

Fine: $14,511

Summary

The facility failed to protect two cognitively impaired residents from sexual abuse. On the evening of 4/4/25, a Medication Aide observed a female resident with advanced dementia and severe cognitive impairment in the room of a male resident, also with severe cognitive impairment and a history of inappropriate sexual behaviors. The female resident was found sitting upright on the male resident's bed, with the male resident standing in front of her with his pants down and his penis inside her mouth. Neither resident had the cognitive capacity to consent to sexual activity, as confirmed by their diagnoses and statements from responsible parties and staff.

The male resident had a documented history of inappropriate sexual behaviors, including disrobing, wandering into other residents' rooms, and making sexual advances or comments. His care plan included interventions such as 1:1 monitoring, redirection, and medication management to address these behaviors. Despite these interventions, he was able to engage in sexual activity with another resident who had no prior history of sexual behaviors and was severely cognitively impaired. The female resident's care plan did not identify any sexually inappropriate behaviors, and she required assistance with activities of daily living and supervision for ambulation.

Staff interviews and record reviews confirmed that both residents were unsupervised at the time of the incident. The Medication Aide immediately separated the residents and notified the nurse, who conducted assessments and found no injuries. Both residents were unable to explain what had happened due to their cognitive impairments. The incident was reported to the appropriate authorities, and both residents were placed on 1:1 supervision following the event. The facility's failure to provide adequate supervision and protection resulted in both residents being subjected to sexual abuse, despite known risk factors and care plan interventions for the male resident.

Removal Plan

• Separated Residents #1 and #2 and placed both on 1:1 supervision following the incident.
• Conducted physical and behavioral assessments of both residents by nursing staff and Director of Nursing, with no injuries noted.
• Notified primary care physician, responsible parties, local police department, and Adult Protective Services of the incident.
• Updated care plans for both residents to include documentation of the incident, 1:1 supervision, specific behavioral interventions, and trauma-informed care approaches.
• Conducted medication review and psychiatric evaluation for both residents, resulting in an increased dosage of mood stabilizer for Resident #2.
• Implemented a plan for continued 1:1 supervision for both residents, with interdisciplinary team reassessment to determine ongoing monitoring needs.
• Interviewed all residents with a BIMS score of 10 or greater to assess for any inappropriate/unwanted sexual contact and feelings of safety.
• Assessed all residents on the secured memory care unit for behaviors using a Behavior Assessment tool.
• Completed comprehensive skin assessments on all residents with a BIMS score of 9 or less to check for signs of abuse.
• Updated sexual history/behavior assessments for all residents to ensure current documentation of risk factors.
• Created a comprehensive list of all residents with behavioral concerns to ensure appropriate monitoring.
• Educated all facility staff (including agency personnel) on abuse prohibition, reporting policy, behavioral monitoring, and dementia-specific training, with mandatory in-service meetings and attestation of understanding.
• Established a behavioral monitoring program for residents with behaviors, including 15-minute, 30-minute, or 1:1 supervision as needed.
• Clarified staff responsibilities for immediate intervention, assessment, documentation, and reporting of behavioral incidents.
• Implemented reviews of progress notes, medication administration records, and care plans for behavior documentation by the Director of Nursing or designee.
• Instituted ongoing monitoring by interviewing staff to ensure continued compliance and awareness.
• Required all findings and monitoring results to be reported to the Quality Assurance Performance Improvement committee for review and further action as needed.