Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Staff
Penalty
Summary
A cognitively impaired resident with a history of stroke, moderate dementia, and mood disorders was involved in a sexual act with a staff member, specifically a housekeeper, within the facility. The incident was witnessed by a CNA, who observed the resident performing oral sex on the housekeeper in the resident's bathroom. The event was reported to the facility administrator and local law enforcement, and the housekeeper was immediately terminated. The resident had a documented history of sexual behaviors with other residents and staff, as reported by multiple employees, but these behaviors were not consistently identified or addressed in the resident's Minimum Data Set (MDS) assessments or care plan documentation. Despite the resident's ongoing sexually inappropriate behaviors, the facility failed to implement adequate interventions or supervision to prevent such incidents. Staff interviews revealed that the resident was known for groping and attempting sexual contact with both staff and other residents, yet there were no specific measures in place to restrict unsupervised access to the resident by male staff or to ensure staff were not alone with the resident. The facility's abuse and neglect policy did not specifically address sexual abuse, nor did it provide clear guidance or training for staff on recognizing, preventing, or intervening in cases of sexual abuse involving residents. The facility's documentation and care planning did not accurately reflect the resident's sexual behaviors or risk for abuse, and there was a lack of physician orders or assessments regarding the resident's capacity to consent to sexual activity. Interviews with facility leadership and clinical staff indicated uncertainty about how to assess sexual consent capacity and how to manage residents with hypersexual behaviors. The failure to identify, document, and address the resident's risk for sexual abuse, combined with insufficient staff training and supervision, directly contributed to the occurrence of sexual activity between the resident and a staff member.