Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a female resident with severe cognitive impairment and a history of Alzheimer's disease, dementia, and stroke was not protected from sexual abuse by another resident. The female resident, who had a BIMS score of 3 indicating severely impaired cognition and was only sometimes able to be understood, was found in a male resident's room without underwear or pants, confused, and unable to walk unassisted. The male resident, who was cognitively intact with a BIMS score of 14 and a history of traumatic brain injury, depression, and drug use, was found in the same room with his pants and underwear down to his thighs. Staff discovered the situation after the female resident was reported missing from her room and a search was conducted. Prior to the incident, the male resident had exhibited concerning behaviors, including attempting to enter female residents' rooms, refusing redirection, and being noncompliant with staff instructions. These behaviors were documented in progress notes, but there was no evidence of effective interventions or increased supervision to prevent further incidents. The male resident's care plan included monitoring for sexually inappropriate behavior, but did not address his drug use or provide specific strategies to prevent access to vulnerable residents. The female resident's care plan noted her tendency to intrude on others' privacy and her cognitive limitations, but did not include interventions related to sexual safety or protection from other residents. On the morning of the incident, staff were unable to locate the female resident during routine rounds and initiated a search. She was eventually found in the male resident's room, disoriented and partially undressed, with physical signs of injury including a swollen lip and bruising. Interviews with staff and family members confirmed that the female resident was unable to make informed decisions or consent to sexual activity, and that the male resident had a history of inappropriate and threatening behavior. The facility failed to implement adequate protective measures despite documented warning signs, resulting in the sexual assault of a vulnerable resident.