Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe dementia and incapacity to make medical decisions was subjected to inappropriate sexual contact by another resident. The incident took place in a common area after dinner, where a staff member witnessed one resident touching the other's breast under their shirt. The victim was unable to communicate or react due to severe cognitive impairment, and there was no evidence of consent. The perpetrator, who also had dementia and lacked capacity for medical decision-making, did not recall the event and displayed indifference when questioned. Prior to the incident, the care plan for the victim did not address the risk of potential victimization, nor was it revised after the event to reflect the new risk. The perpetrator's care plan noted moderate cognitive impairment and behavioral concerns, with interventions to monitor interactions for appropriateness, but there was no documented history of prior inappropriate behavior. Staff interviews confirmed that the incident was recognized as sexual abuse, and immediate separation of the residents occurred. However, documentation and monitoring for the safety of the victim and prevention of recurrence were not clearly established at the time of the incident. The facility's abuse prevention policy required protection of residents from abuse and outlined steps such as increased supervision and room changes to safeguard victims during investigations. Despite these policies, the lack of a care plan addressing the victim's vulnerability and the absence of immediate, documented interventions to prevent further abuse contributed to the deficiency. Staff responses varied in their understanding of the incident, with some not recognizing the event as abuse due to the perpetrator's cognitive status, while others identified it as non-consensual sexual contact.