Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer’s, dementia, and other conditions was not protected from sexual abuse by another resident. The incident took place in a memory care unit, where the resident, who was independently ambulatory and known to wander, entered the bathroom of another resident. This second resident also had severe cognitive impairment and a history of hypersexuality, for which he was receiving medication and had a physician order for one-on-one staff monitoring around female residents. A licensed social worker observed the incident, finding the first resident standing in the bathroom with her pants at her ankles and the other resident, seated in a wheelchair, with his hand inside her brief. Both residents displayed flat affect and did not respond to questioning. The residents were separated without resistance, and the incident was reported to the nurse, police, and the resident’s guardian. The affected resident was sent to the hospital for a Sexual Assault Nurse Exam (SANE), which found no evidence of sexual penetration or injury, but did note incontinence-associated dermatitis. Facility records and interviews confirmed that the resident with hypersexual behaviors had a history of such conduct and was supposed to be under one-on-one monitoring. Despite this, the incident occurred, indicating a failure to ensure adequate supervision and protection for vulnerable residents. The facility’s policy defined sexual abuse as non-consensual sexual contact of any type, and the event was reported as a state reportable incident.