Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents with cognitive impairments. One resident with severe dementia and another with moderate cognitive impairment were both determined, through Sexual Capacity Evaluations, to lack the capacity to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents, but there was no evidence that an investigation into the incidents was conducted. The administrator confirmed that it was his responsibility to complete such investigations but was unable to locate any documentation that an investigation had occurred.