Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with severe dementia from sexual abuse. One resident with Alzheimer's disease and a severely impaired BIMS score was observed by another resident and an activity aide making physical contact and placing his hand inside the diaper area of another resident, who was also severely cognitively impaired and on hospice care. The incident occurred in the activity room, where the resident was seen with his hand inside the other resident's pants, and staff were alerted by a witness. The staff intervened and separated the residents after the inappropriate contact was observed. Both residents involved were unable to provide details about the incident due to their cognitive impairments. The event was reported to facility management and a body assessment was conducted on the resident who was touched, with no injuries found. The care plan for the resident at risk for abuse noted interventions to keep her safe, but the incident still occurred. The facility's policy affirms residents' rights to be free from abuse, including sexual abuse, but the failure to prevent this incident resulted in a deficiency.