Failure to Prevent and Address Sexual and Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to recognize, prevent, and appropriately respond to incidents of sexual abuse and neglect among residents, particularly those with cognitive impairments. Multiple staff interviews and record reviews revealed that several residents, many with moderate to severe cognitive impairment as indicated by low BIMS and SLUMS scores, engaged in sexual activities with other residents who were unable to consent. Staff were aware of these activities but did not assess the residents' capacity to consent, and in some cases, relied on family or POA consent rather than the residents' own ability to make decisions. Documentation showed repeated incidents where residents with severe cognitive impairment were involved in sexual acts, and staff either did not intervene or were instructed to allow the acts to continue if already in progress. The facility's administrative staff, including the Administrator and DON, were aware of ongoing sexual activities but did not implement measures to ensure resident safety or comply with facility policies regarding abuse and neglect. Care plans lacked individualized information about sexual behaviors, preferences, risks, or interventions, and there was no formal process to assess or address the ability of residents to consent to sexual activity. Staff did not conduct behavioral or cognitive assessments following incidents, and events were not reported to the State Survey Agency as required. The facility's abuse and neglect policy was found to be insufficient, lacking specific guidance on alleged or potential sexual abuse, and staff training did not adequately address these issues. Additionally, the facility failed to protect a resident from physical abuse by a staff member, resulting in a skin tear when a staff member forcefully attempted to retrieve medication from the resident's hand. The incident was documented, and the staff involved were removed from resident care. However, the overall failure to recognize, assess, and prevent abuse and neglect, particularly in relation to sexual activity among cognitively impaired residents, constituted a significant deficiency and led to an Immediate Jeopardy finding.