Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by a roommate. One resident with dementia and Alzheimer’s disease, documented as severely impaired in cognitive skills for daily decision-making and dependent or needing assistance with most ADLs, was lying in bed when another resident entered his space. The cognitively impaired resident required assistance with transfers, dressing, personal hygiene, and eating, and was not able to provide meaningful information during post-incident interviews, only being able to state his name. The Director of Nursing later stated that this resident did not have the ability to consent to sexual activity. A second resident, also diagnosed with dementia and polyneuropathies and severely impaired in cognitive skills for daily decision-making, was identified as the perpetrator of the sexual contact. This resident required varying levels of assistance with transfers, dressing, personal hygiene, and eating, and was unable to recall the incident when interviewed. On the date of the incident, a CNA entered the shared room while passing dinner trays and observed the second resident on his knees at the side of the first resident’s bed, with the first resident’s diaper open, and using both hands to touch the first resident’s private parts. The CNA estimated that the touching continued for approximately 10 seconds from the time she first observed it until she intervened. Another cognitively intact resident reported having previously witnessed the same perpetrating resident lowering the first resident’s diaper and touching his buttocks in the shared room. This witness stated he reported what he saw to an unidentified staff member, but the facility was unable to identify who received that report and was unable to substantiate that earlier allegation. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including sexual abuse, and that the administration will protect residents from abuse by anyone, identify and assess all possible incidents of abuse, and investigate and report any allegations of abuse within required timeframes. Despite these policies, the observed non-consensual sexual contact occurred between the two residents, constituting a failure to protect the first resident’s right to be free from sexual abuse. The facility’s documentation following the incident reflected that the first resident experienced unwanted touching behavior and was at risk for emotional/psychological distress due to possible unwanted touching behavior by another resident. The second resident’s documentation reflected possible unwanted touching behavior as well. The survey findings concluded that the facility failed to protect the first resident from sexual abuse by the second resident when the second resident was observed playing with the first resident’s private part, and that this failure resulted in sexual abuse and had the potential to result in negative psychosocial effects based on the reasonable person concept, given the first resident’s severely impaired cognitive status.
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