Failure to Protect Resident from Sexual Abuse and Inadequate Documentation of Consent
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, despite having policies in place prohibiting abuse, mistreatment, and neglect. On the date of the incident, a certified nurse aide observed one resident fondling another resident's private areas in a common area. The facility's investigation did not document critical details such as the specific areas touched, whether the touching was over or under clothing, or include signed witness statements from staff. The investigation also failed to clarify whether the relationship between the two residents was consensual, as there was confusion regarding the identity of the resident with whom the victim had a prior relationship. The resident who was the victim had diagnoses including multiple sclerosis, generalized muscle weakness, and unspecified dementia, with documented cognitive decline and dependence on staff for daily care. The resident's representative stated that the resident would not be able to understand or consent to intimate contact due to her dementia and was not aware of any relationship with the alleged perpetrator. The care plans and medical records for both residents did not contain updated interventions, documentation of behavior monitoring, or sexual consent assessments following the incident. There was also no evidence that the residents' representatives were properly informed or that the care plans were revised to address the incident. Staff interviews revealed inconsistent knowledge and documentation regarding monitoring for inappropriate touching and consent. Some staff believed monitoring was in place, but there was no supporting documentation in the medical records. The facility administrator acknowledged that there was no formal assessment tool for determining capacity to consent to sexual relationships, and the medical director indicated that consent should be obtained from representatives for residents with dementia. However, no such documentation was found, and the investigation relied on assumptions about the residents' relationship without confirming consent or informing the appropriate parties.