Failure to Prevent and Address Repeated Non-Consensual Intimate Contact Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to prevent a male resident with severe dementia and a history of behavioral issues from repeatedly kissing a female resident who was also severely cognitively impaired. Both residents were unable to consent to intimate contact, as confirmed by their BIMS scores and staff interviews. Multiple staff members, including CNAs and an LPN, observed the male resident initiating and forcing kisses on the female resident, sometimes by grabbing her head or entering her room while she was sleeping. Staff reported that these incidents had been ongoing for over a month, with the male resident also attempting similar behavior with another cognitively impaired resident. Despite these repeated incidents, there was no care plan in place addressing the female resident's risk for abuse or her vulnerability, nor was there an assessment for her ability to consent to intimate behaviors. Interviews revealed that staff were aware of the ongoing inappropriate behavior but believed there was little they could do due to the residents' dementia. The facility's abuse prevention policy required identification of residents at increased risk for abuse and notification of incidents, but the administrator and nurse practitioner were unaware of the ongoing incidents until informed by surveyors. Documentation showed prior instances of sexually inappropriate behavior by the male resident, yet no interventions or care planning were implemented to address or prevent further occurrences.