Failure to Protect Cognitively Impaired Residents from Abuse, Neglect, and Unassessed Sexual Contact
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, specifically failing to ensure that residents with severe cognitive impairment were free from sexual abuse and neglect. Several residents with diagnoses such as dementia, Alzheimer's disease, traumatic brain injury, and other cognitive disorders were involved in repeated incidents of sexual contact without documented assessments of their capacity to consent. In multiple cases, residents with severe cognitive impairment were found engaging in sexual acts or intimate behaviors with other residents, and staff determined these interactions to be consensual based on superficial observations, such as the absence of resistance or distress, rather than formal capacity assessments. There was no evidence in the medical records that any of the involved residents had been evaluated for their ability to consent to sexual activity, despite clear documentation of severe cognitive deficits and fluctuating mental status. The report details several specific incidents, including residents being found undressed together, engaging in sexual acts, or being discovered in each other's rooms. In one case, a resident with a BIMS score of 3 and a MOCA score of 7, both indicating severe cognitive impairment, was repeatedly found in intimate situations with other residents, some of whom also had severe cognitive impairment. Staff and administration often relied on the residents' apparent comfort or lack of protest to determine consent, even when family members and staff acknowledged the residents' confusion and inability to understand their circumstances. In another case, a resident with a traumatic brain injury and aphasia was found in a sexual situation with another cognitively impaired resident, and the facility failed to conduct or document an abuse investigation or implement effective safety measures to prevent recurrence. Additionally, the facility failed to prevent neglect in the form of elopement, as two residents were able to leave the facility and return without staff knowledge. The lack of supervision and failure to update or implement appropriate care plan interventions for residents at risk of elopement further contributed to the finding of neglect. The surveyors identified these failures as Immediate Jeopardy, citing the facility's lack of adherence to Centers for Medicare and Medicaid Services recommended practices to prevent abuse and neglect, and the absence of thorough investigations and documentation regarding incidents of sexual contact and elopement among cognitively impaired residents.