Failure to Prevent Repeated Sexual Abuse Between Residents with Dementia
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from repeated unwanted sexual contact by another resident, also with severe cognitive impairment. On the day of the incident, a staff member observed one resident with his face in the breast area of another resident in the lounge. When questioned, the resident stated he was just talking to her. The affected resident was removed to a safer location near the nurse's station, and the other resident was redirected to his room and counseled. Despite these interventions, the same resident was observed again shortly after kissing the affected resident on the mouth in the lounge, and later, touching her inappropriately. The affected resident was noted to have wandering behaviors and frequently entered the lounge area, which was monitored by the facility's camera system. The inappropriate sexual contact occurred three times within a short period before the facility implemented one-to-one supervision for the resident exhibiting the sexual behaviors. Both residents had diagnoses of dementia and were identified as having severe cognitive impairment on their Minimum Data Set assessments. The facility's policy stated that all residents have the right to be free from abuse, including sexual abuse, and that residents must not be subjected to abuse by anyone, including other residents. However, the facility did not prevent the repeated incidents of nonconsensual sexual contact before taking more intensive supervisory action.