Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with impaired cognition from sexual abuse by another resident. During post-lunch rounds, a cognitively impaired resident with a legal guardian was found in another resident's room, engaged in oral sexual contact. The incident was interrupted by a CNA, who observed the cognitively intact resident standing between the beds with their genitalia exposed and the impaired resident engaged in the act. The impaired resident was unable to recall the incident during subsequent interviews, while the other resident reported believing the act was consensual. Both residents required staff assistance with bed mobility and transfers, and the resident with impaired cognition had been deemed incompetent by the court system. At the time of the incident, staff were not present in the room, as they were reportedly picking up lunch trays, despite the room being directly across from the nurse's station and the door being open. The facility's policy states that residents must be free from all forms of abuse, including sexual abuse. The lack of adequate supervision and failure to prevent access to a vulnerable resident resulted in the occurrence of sexual contact without the ability to ensure proper consent, constituting a failure to protect residents from abuse.