Failure to Prevent Resident-to-Resident Sexual Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident, both with severe cognitive impairments, was able to physically touch the first resident inappropriately in a common area. The incident occurred when one resident, diagnosed with Alzheimer's disease, dementia with agitation, and delusional disorder, was walking through the memory care unit and was approached by another resident with Alzheimer's disease, a history of traumatic subdural hemorrhage, and mild cognitive impairment. The second resident, who had a documented history of behavior problems related to sexual outbursts and grabbing staff, reached out and ran a hand up the inside of the first resident's thighs, grabbing the genital area as the first resident walked by. At the time of the incident, the first resident had severely impaired cognition, displayed wandering behavior, and was sometimes understood in communication. The second resident also had severely impaired cognition and was noted to have behavior problems, including sexual outbursts, with care plan interventions instructing staff to redirect and distract the resident when inappropriate behaviors occurred. The incident was witnessed by a Certified Medication Technician (CMT) who was preparing medications in the common area and observed the inappropriate contact as it happened. Both residents were in the common area of the memory care unit, unsupervised in close proximity, despite the known behavioral risks associated with the second resident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including other residents, but the measures in place at the time did not prevent the incident from occurring. The event was reported to the charge nurse, and both residents were assessed with no injuries noted.