Failure to Implement Abuse Prevention and Consent Assessment Policies
Penalty
Summary
Surveyors identified that the facility failed to implement and follow written policies and procedures to prevent abuse, neglect, and theft, specifically regarding sexual abuse, capacity to consent to sexual activity, and elopement. The facility did not have written definitions or protocols for evaluating a resident's capacity to consent to sexual relationships, nor did it have adequate procedures for investigating and reporting allegations of abuse. Multiple incidents involving residents with severe cognitive impairment engaging in sexual contact or being found in compromising situations were documented without evidence of proper assessment of their ability to consent or thorough investigation of the events. Several residents with diagnoses such as dementia, traumatic brain injury, and other cognitive disorders were involved in incidents of sexual contact or attempted sexual contact. For example, one resident with a BIMS score indicating severe cognitive impairment was found in multiple situations involving physical intimacy with other residents, none of whom had documented assessments of their capacity to consent. Another resident with a history of neurocognitive disorder and severe cognitive impairment was found in other residents' rooms and beds, sometimes with residents who were partially undressed or engaged in physical contact. In one case, a resident was found with her underwear down and another resident attempting to initiate sexual contact, but there was no documentation of an abuse investigation or capacity assessment. The facility's records showed repeated failures to document or conduct assessments for capacity to consent to sexual activity, despite clear evidence of cognitive impairment and repeated incidents. Incident reports and progress notes often described the events as consensual or inconclusive without supporting documentation or proper evaluation. In some cases, incidents were not reported to the State Survey Agency or law enforcement as required, and there was no evidence of timely or thorough investigation into allegations of abuse or neglect. These failures were cited at the Immediate Jeopardy level due to the facility's lack of effective policies and procedures to prevent and address abuse, neglect, and elopement.