Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents' rights to be free from sexual abuse, resulting in a deficiency cited at F-600. One resident with severe cognitive impairment and a history of dementia-related behaviors, including hypersexuality and confusion, displayed inappropriate and unwanted behaviors toward other residents. Despite staff observing these behaviors and reporting them to nursing leadership, no immediate interventions were implemented to monitor or manage the resident's hypersexual behaviors while awaiting the administration and evaluation of prescribed medication. Documentation shows delays in medication administration and a lack of consistent monitoring or supervision during this period. Subsequently, a certified nursing assistant discovered the two cognitively impaired residents, both lacking capacity to consent, engaged in sexual activity in a resident's room. Interviews with staff and family members confirmed that both residents would have been unable to consent and that the incident likely caused psychosocial trauma. Staff interviews revealed that there was no increased monitoring or supervision in place prior to the incident, and care plan interventions were limited to redirection and attempts to keep the resident engaged, without specific measures to prevent inappropriate sexual contact. Medical records and staff documentation indicated ongoing sexually inappropriate behaviors, wandering, and delusional thinking by the resident both before and after the incident. Observations during the survey also revealed continued affectionate and inappropriate touching toward other male residents, with staff unable to provide consistent supervision. The facility's policy required identification, assessment, care planning, and monitoring for residents with behaviors that could lead to conflict or neglect, but these steps were not adequately implemented, resulting in a failure to prevent sexual abuse between vulnerable residents.