Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and dementia from sexual abuse by another resident with moderate cognitive impairment and Alzheimer's. The first incident occurred when a resident with dementia, who was unable to consent to sexual relations, was found in another resident's room with her shirt lifted and her breasts exposed, while the other resident was touching her breasts. This was observed by a CNA, who did not immediately intervene but instead left to notify an RN. When staff returned, the resident was still in the room and was then redirected out. The CNA later reported she was unsure of what to do at the time and received education from the RN about appropriate intervention. The resident's care plan indicated she could not consent to sexual activity, and the other resident's care plan noted a history of sexually inappropriate behavior. A second incident occurred when the same two residents were observed in the main dining room, with the resident with Alzheimer's rubbing the other resident's leg and buttocks over her clothing. Maintenance staff separated the residents, and an LPN was notified. The facility had been aware of the previous incident but did not prevent further contact between the two residents, resulting in repeated inappropriate interactions. Both residents had significant cognitive impairments, and the facility failed to implement effective measures to prevent further abuse, as evidenced by the recurrence of inappropriate contact.