Failure to Prevent Sexual Assault Due to Inadequate Supervision of Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents with cognitive impairments. One resident, who was severely cognitively impaired, nonverbal, and at high risk for wandering, was care-planned for elopement risk and had a history of entering male residents' rooms. Despite interventions such as structured activities, a wander guard, and redirection, the resident continued to wander into other residents' rooms. The care plan also identified the resident as a trauma survivor with a history of abuse, and she required substantial assistance with activities of daily living and was always incontinent. Another resident, who was moderately cognitively impaired and had a documented history of making inappropriate sexual comments to staff, was care-planned for behavior problems and potential physical aggression. This resident had a BIMS score indicating moderate cognitive impairment and was receiving psychotropic medication. The care plan included interventions such as redirection and psychiatric consultation, but there was no evidence of increased supervision or restriction of access to other residents' rooms despite the behavioral concerns. On the date of the incident, the severely cognitively impaired resident wandered into the room of the resident with behavioral issues, where staff discovered a sexual assault in progress. Staff interviews confirmed that the resident with behavioral issues had previously assisted female residents in the bathroom and that the cognitively impaired resident frequently entered his room. The facility's interventions, such as making frequent rounds and redirecting the wandering resident, were ineffective in preventing the incident. The facility did not implement one-on-one supervision or other enhanced monitoring measures prior to the event, despite the known risks and previous behaviors.