Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident who also had significant cognitive and behavioral issues. The incident involved a male resident with diagnoses including dementia, severe cognitive impairment (BIMS score of 5), and a history of wandering into female residents' rooms. Despite being identified as having the potential for physical behaviors related to dementia, the male resident was not adequately supervised, and on the date of the incident, he was found by a CNA in a female resident's room with his hand under her brief, touching her genital area. The female resident was also severely cognitively impaired, unable to consent, and had a history of stroke, aphasia, and hemiplegia. Prior to the incident, the male resident had been observed frequently entering other residents' rooms, particularly those of female residents, under the pretense of looking for his mother or wife. Observation logs indicated that he had been placed on intermittent increased observation at night due to his wandering, but these measures were not sufficient to prevent the incident. The female resident's care plan noted a psychosocial well-being problem related to a previous abuse allegation, but interventions focused on communication and referrals rather than enhanced supervision or protection from other residents. Staff interviews and record reviews confirmed that the facility had provided training on abuse, neglect, and misappropriation of property, and staff were aware of reporting protocols. However, the actions taken to monitor and supervise the male resident were not effective in preventing the abuse of the female resident. The failure to provide adequate supervision and protection resulted in a witnessed incident of nonconsensual sexual contact, constituting a failure to ensure residents' rights to be free from abuse and neglect.