Failure to Prevent Non-Consensual Sexual Contact Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with impaired cognition from sexual abuse, as both were involved in an incident of non-consensual sexual contact. A certified nurse aide discovered one resident lying on another resident's bed with her shirt pulled up while the other resident was touching her breasts. Both residents were known to have severe cognitive impairment due to Alzheimer's disease and dementia, and neither had the capacity to consent to sexual activity. The incident was observed by staff, and both residents were immediately separated. Review of the medical records revealed that one resident had a history of unpredictable behaviors, wandering, removing her clothes, and being found in other residents' rooms. The other resident had a documented history of making inappropriate comments to female staff, occasional episodes of cursing, rejection of care, and a prior episode of touching a female resident's breasts. Both residents were on a secured unit and had very poor short-term memory, with care plans indicating the need for monitoring and interventions to prevent inappropriate interactions. Despite these known risks and behavioral histories, the facility did not prevent the incident of non-consensual sexual contact between the two residents. Staff interviews confirmed that neither resident showed distress at the time, and both lacked the cognitive ability to remember or consent to the event. The failure to ensure adequate supervision and monitoring led to the occurrence of sexual abuse as defined by the facility's policy.