F0607

D

Failure to Implement Abuse Prohibition Policy After Alleged Sexual Incident Between Cognitively Impaired Residents

Safford, Arizona Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse prohibition policy and to investigate and report an allegation of possible sexual abuse between two cognitively impaired residents. One resident had early onset Alzheimer’s disease, aphasia, depression, a BIMS score of 00 indicating severe cognitive impairment, and a care plan noting behavior problems including poor safety awareness, wandering, exit seeking, and later, lifting her shirt and exposing her breasts. Despite this, the care plan interventions were not revised when the behavior of lifting her shirt was added, and there were no progress notes documenting this behavior or the alleged incident. The second resident had dementia with behavioral disturbances, type 2 diabetes, depression, a BIMS score of 09 indicating moderate cognitive impairment, and a care plan that identified sexually inappropriate behavior, but the care plan was not revised after the incident to reflect modified interventions related to sexual behaviors.

Progress notes for the second resident showed that he was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note documented that he was observed kissing the first resident and that the first resident was reciprocating, but no additional progress notes were found related to this alleged incident. An observation showed that the two residents’ rooms were directly across the hallway from each other. Review of the state agency complaint portal revealed that no facility-reported incident had been submitted regarding these two residents, despite the facility’s policy requiring investigation and reporting of allegations of abuse within required timeframes and protection of residents from further harm during investigations.

Multiple staff interviews revealed inconsistent and incomplete responses to the incident and a failure to treat it as a reportable allegation of abuse. A CNA stated that suspected abuse should be reported to the administrator, described the first resident as nonverbal and unable to give consent due to cognitive impairment, and expressed concern that having the residents’ rooms across from each other was not safe. An RN reported being told at shift change that there had been inappropriate behavior between the two residents but was unsure what occurred and noted that the residents should be moved. Another RN stated she had been told that the male resident was kissing the female resident on the cheek and that she had recommended moving them but was told only to keep them separated. The DON reported that both residents were found in the male resident’s room with the female resident’s shirt up, that they were separated, and that the facility concluded no sexual abuse had occurred; she acknowledged the incident was not reported to the state and could not say with 100% certainty that nothing had happened. The administrator, serving as abuse coordinator, confirmed that staff reported the residents were in bed together, fully clothed, and that the female resident could not consent, yet he did not consider the situation abuse and did not report it. The written statement from the witnessing RN described the female resident in bed with her shirt off and the male resident hovering over her; this RN stated she separated them and reported the incident because both residents were not alert and oriented and could not consent, but she personally did not label it as sexual abuse. Despite the facility’s policy defining abuse to include sexual abuse and requiring investigation and reporting of allegations, the incident was not reported to the state, the residents were not clearly protected through care plan revisions or room changes, and the facility did not fully implement its abuse prohibition policy.