Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, including Alzheimer's dementia and aphasia, from sexual abuse by another resident. The incident occurred when a CNA found the cognitively impaired resident in another resident's room, with her/his hands on the other resident's genitals. The resident was redirected to her/his own room and exhibited unusual behavior afterward, such as refusing care and being naked, which was not typical for this resident. The resident had no memory of the incident, and interviews confirmed the resident's inability to consent due to cognitive loss. The other resident involved had a history of making inappropriate comments and watching pornography in the facility. Despite the incident, a review of the medical record and care plan revealed that no interventions were implemented to ensure the safety of the resident following the event. There was no documentation of new safety measures or care plan updates addressing the incident or the behavior of the other resident. Additionally, the family was not promptly notified of the incident, and the administrator acknowledged that appropriate interventions were not put in place due to delayed reporting.