Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident. On 4/19/2025, a Licensed Practical Nurse observed a resident with moderately impaired cognition inappropriately touching and kissing a resident who was not alert and aware, as evidenced by a BIMS score of 5 out of 15 and a diagnosis of Alzheimer's disease. The incident was reported to the Rhode Island Department of Health, and documentation confirmed that the resident who was touched could not consent to intimate contact due to cognitive impairment. The facility's own policy defines sexual abuse as non-consensual sexual contact, including unwanted intimate touching, especially when the resident lacks the capacity to consent. Interviews with staff, the resident's family, and facility leadership confirmed that the resident was unable to consent and that the family did not approve of any intimate relationship. The resident who committed the act was sent for psychiatric evaluation, and the facility moved this resident to a different unit. However, the facility was unable to provide evidence that adequate measures were in place to prevent the incident or to keep the cognitively impaired resident free from abuse, resulting in a failure to protect the resident as required.