Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, communication difficulties, and a history of paranoid schizophrenia from sexual abuse by another resident. The resident was dependent on staff for hygiene, dressing, and transfers, and her care plan had not been updated for an extended period. Despite her inability to provide informed consent, she was observed in two separate incidents involving inappropriate sexual contact with another resident. In the first incident, a nurse observed the two residents kissing in a common area and intervened to separate them. The event was reported to management, and staff were instructed to keep the residents apart. However, the care plan for the cognitively impaired resident was not updated following this event, and there was no documented reassessment of her vulnerability or supervision needs. A second, more serious incident occurred when a staff member found the same male resident in the female resident's room, on her bed with his pants down. The male resident was removed and placed on one-on-one observation only after this event. The female resident was sent to the emergency room for a rape kit, which was later reported as negative. The facility's policy required protection of residents who may lack capacity to consent to sexual activity, but the failure to maintain separation and update care planning led to a repeat incident.