Failure to Prevent Sexual Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to prevent sexual abuse involving three residents with moderate cognitive impairment and histories of inappropriate or aggressive behaviors. One resident, with diagnoses including schizoaffective disorder and cognitive communication deficit, had a documented history of sexually inappropriate actions such as exposing himself, masturbating in public areas, and entering female residents' rooms. On multiple occasions, this resident was found in another resident's room with his penis exposed, and was observed touching the other resident's breast over her clothing. Staff interviews and witness statements confirmed these incidents, including the resident exposing himself and masturbating in common areas and in front of other residents. Another resident involved had diagnoses of dementia and obsessive-compulsive disorder, and was also moderately cognitively impaired. This resident was found in situations where she was exposed to the inappropriate behaviors of the first resident, including being touched and exposed to indecent acts. The resident did not recall the incident during interview but was identified as a victim in the facility's self-reported incident and staff statements. A third resident, with vascular dementia and major depressive disorder, was also subjected to the first resident's inappropriate sexual behaviors, including exposure and masturbation in their presence. Staff interviews corroborated that the first resident repeatedly exposed himself and engaged in sexual acts in front of other residents. The facility's policy defined such actions as sexual abuse, and the events were substantiated through medical record review, staff and resident interviews, and facility documentation.