Failure to Prevent Sexual Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident. One resident, diagnosed with severe dementia and dependent on staff for all activities of daily living, was found in bed and unable to communicate or participate meaningfully in assessments. Another resident, with moderate cognitive impairment and a history of confusion and inappropriate sexual behaviors, was observed by an LPN kneeling next to the first resident's bed with her pants down and her hand in the other resident's buttocks region. The LPN witnessed the resident placing her finger near the other resident's rectum and immediately intervened. The resident who initiated the contact had a documented history of dementia, confusion, and previous sexual behaviors, including self-stimulation and confusion about boundaries. Despite these known risks, the resident was able to access and interact with the other resident, who was incapable of providing consent or resisting advances due to her cognitive and physical limitations. The incident was witnessed by staff, and the resident was unable to explain her actions clearly, offering inconsistent explanations such as attempting to help or being cold. The affected resident's medical records confirmed severe cognitive impairment, total dependence on staff, and inability to communicate. Staff interviews and documentation indicated that the resident could not report or describe the incident. The facility's failure to prevent this interaction resulted in inappropriate physical contact of a sexual nature, violating the resident's right to be free from abuse and neglect.