Failure to Protect Residents from Sexual and Physical Abuse Due to Lack of Policy and Inadequate Care Planning
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse, as evidenced by two separate incidents involving three residents. In the first incident, a staff member observed a male resident with moderate cognitive impairment (BIMS scores of 10-11, diagnosed with dementia) with his mouth on the breast of a female resident with severe cognitive impairment (BIMS scores of 6-7, also diagnosed with dementia). The female resident was assessed as lacking the capacity to make informed decisions, and both residents' care plans did not address the incident or any sexual behaviors. Interviews with staff revealed that the care plans should have been updated to reflect the incident, but this was not done. The facility did not have a policy or procedure in place to assess or determine capacity to consent to sexual activity, and there was no documentation or assessment of consent for sexual activity in the residents' records or admission packets. In the second incident, a male resident with intact cognition and total dependence on staff for toileting care reported that a CNA pushed his face into the bed railings during incontinence care. The resident stated he had to yell at the CNA to stop and subsequently requested that she no longer provide care to him. The resident did not sustain injuries or report feeling unsafe, but described the CNA as typically rough and rude. Other residents had previously complained about the CNA's care, and staff interviews confirmed that her demeanor was often perceived as combative or assertive. The facility did not have documentation of prior interventions or conversations with the CNA regarding her care practices. The facility's policies at the time did not address the determination of capacity to consent to sexual activity, nor did they provide guidance on how to assess or document such capacity. Staff interviews indicated a lack of clarity and responsibility regarding updating care plans after behavioral incidents. The facility's abuse and neglect policy did not include procedures for assessing consent to sexual activity, and the admission packet did not address this issue. The absence of these policies and procedures contributed to the failure to protect residents from abuse and to ensure their care plans reflected significant incidents affecting their safety and well-being.