Failure to Report Sexual Abuse Allegations Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report multiple witnessed and documented incidents of sexual abuse involving three residents who lacked the capacity to consent to sexual activity. Staff observed a resident with a history of sexually inappropriate behaviors, including rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. Despite these incidents being documented in progress notes and discussed among staff, there was no evidence that the events were reported to the state agency or to the residents' representatives as required by facility policy and federal regulations. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, and major depressive disorder with psychotic symptoms, and were documented as having impaired judgment and decision-making abilities. The facility's own policies required prompt reporting of all allegations of abuse to appropriate authorities and to the residents' representatives, as well as evaluation of capacity to consent for any resident involved in sexual activity. However, there was no documentation of such evaluations or notifications in the residents' records, and interviews with representatives confirmed they were not informed of the incidents. Interviews with staff revealed a lack of clarity and follow-through regarding reporting responsibilities. Some staff believed the behaviors were not abuse due to the perpetrator's cognitive status, while others assumed incidents had already been reported or did not recognize the need to report. Leadership, including the DON and Administrator, were unaware of the incidents until much later and acknowledged that the events should have been reported according to policy. The failure to report these incidents constituted a violation of both facility policy and regulatory requirements.