Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A resident with severe cognitive impairment, including a diagnosis of focal traumatic brain injury and frontotemporal neurocognitive disorder, was not protected from sexual abuse by another resident. The cognitively impaired resident, who had a BIMS score of 7 indicating severe impairment, was observed sitting in a common area when another resident, who was cognitively intact, sat beside them and engaged in inappropriate sexual touching. Staff immediately intervened and separated the two residents, but the incident had already occurred. The cognitively impaired resident was unable to recall or participate in an interview about the event due to their condition, and a family member confirmed that the resident was not capable of consenting to sexual advances. The facility's abuse policy and sexual consent policy both require protection of residents from abuse and specify that consent must be based on intact decision-making ability. Despite these policies, the incident occurred in a common area, and the resident at risk was not adequately protected from inappropriate contact. The event was documented in nursing notes and reported to the state health department. Prior to the incident, there was no indication of a relationship or interaction between the two residents beyond casual greetings.