Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse, as required by its own policy and federal regulations. The incident involved a resident with severe cognitive impairment, including traumatic brain injury and paranoid schizophrenia, who entered the room of another resident with moderate cognitive impairment and dementia. The first resident was found in bed with the second resident, both unclothed from the waist down, engaging in inappropriate sexual contact. The event was witnessed by a CNA, who left the room to find a nurse, and the nurse subsequently intervened to separate the residents. Medical record reviews indicated that both residents had significant cognitive deficits, with one unable to complete a mental status interview and the other displaying moderate impairment and short-term memory loss. The facility's policy outlined the need to prevent all forms of abuse, including sexual abuse, and to identify residents at increased risk, such as those with confusion or behavioral disturbances. Despite these policies, the residents were left unsupervised, and the incident was not immediately interrupted when first discovered by staff. Camera footage confirmed that the residents remained together and unattended for a period after the inappropriate interaction was witnessed. Interviews with staff revealed that there was no prior history of sexual aggression for either resident, and that staff were aware of the cognitive and behavioral challenges faced by both individuals. The CNA who discovered the incident did not immediately separate the residents but instead left to find a nurse, resulting in a delay. The nurse who responded found both residents unclothed and intervened to remove the first resident from the room. The incident was reported to law enforcement and Adult Protective Services, and both residents were subsequently monitored in separate locations.