Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A severely cognitively impaired resident with diagnoses including schizophrenia, bipolar disorder, diabetes, anxiety disorder, and dementia was sexually abused by another resident. The incident occurred when a male resident, who was cognitively intact and ambulatory with a walker, entered the female resident's room, lifted her top, and touched and sucked on her breasts. The female resident was lying in bed, did not move or resist, and later could not recall the incident when questioned by staff and law enforcement. The male resident stated he believed the contact was consensual and that he was trying to make friends with the female resident. Two housekeepers witnessed the male resident engaging in the inappropriate sexual contact but did not intervene to stop the abuse. Instead, one housekeeper remained in the room while the other sought assistance. By the time a registered nurse arrived, the male resident had ceased the contact, adjusted the female resident's clothing, and left the room. The nurse assessed the female resident and found no injuries or signs of distress, and the incident was reported to facility administration and local law enforcement. The facility's policy stated that residents should be protected from sexual abuse and that steps should be taken if a resident might lack the capacity to consent to sexual activity. Despite this, the staff failed to prevent or immediately stop the abuse, resulting in actual harm to the cognitively impaired resident. The incident was substantiated by witness statements, medical assessments, and interviews with both residents and law enforcement.