Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of wandering from sexual abuse by another resident. The resident, who was nonverbal, unable to make her needs known, and had diagnoses including anoxic brain damage, epilepsy, and dementia, was care-planned for high elopement risk and wandering into male residents' rooms. Despite these known risks, the primary intervention was redirection and frequent staff rounds, with no one-on-one supervision or more restrictive measures implemented. The resident's care plan also identified her as a trauma survivor with a history of sexual abuse, further emphasizing her vulnerability. On the date of the incident, the cognitively impaired resident wandered into another resident's room, where staff discovered her and a male resident engaged in sexual activity. Eyewitness accounts from CNAs described the male resident standing behind the female resident with both of their clothes pulled down and semen present. The male resident, who had a history of making inappropriate sexual comments and was care-planned for behavioral issues related to dementia, admitted to assisting the female resident in the bathroom but denied sexual intercourse. However, staff and medical professionals determined that the female resident was not capable of consenting to sexual activity due to her cognitive status. Following the incident, the female resident was sent to the hospital for a forensic examination and received prophylactic treatment for potential sexually transmitted infections and pregnancy. Interviews with staff and administration revealed that the facility did not have policies or education in place regarding resident-to-resident sexual interactions or safe consensual sex. The male resident was placed on one-on-one supervision only after the incident, and it was noted that staff were aware of the female resident's frequent wandering into his room prior to the event. The facility's failure to implement effective interventions to prevent the resident's wandering and protect her from abuse led to the identified deficiency.