F0600

G

Failure to Assess, Care Plan, and Monitor Resident With Known Sexually Inappropriate Behavior Resulting in Sexual Assault of a Cognitively Impaired Resident

Los Angeles, California Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its Abuse and Neglect Prohibition Policy and related safety policies, resulting in a resident with severe cognitive impairment being sexually assaulted by another resident with known sexually inappropriate behaviors. The cognitively impaired resident had spastic quadriplegic cerebral palsy, depression, schizoaffective disorder, and was conserved, with an MDS showing severe cognitive impairment and need for staff assistance with mobility and lower body dressing. On the date of the incident, progress notes documented that this resident was found lying in bed with lower garments down and did not respond when asked if she was in pain or knew what had happened. A change of condition assessment noted that a CNA had informed the charge nurse that a male resident was in the room, but the assessment did not document what occurred prior to the residents being separated or specify the details of the vaginal exam performed.

The male resident involved had a documented history of sexually inappropriate behavior prior to admission. Hospital records from a recent stay indicated he had confusion, frequent wandering, and a history of depression, bipolar disorder, and schizophrenia, and that he had displayed sexually inappropriate behavior, including masturbating while looking at a CNA, leading to placement on precautions for sexually inappropriate behavior. A facility document summarizing the nursing report at admission showed that the admitting RN was informed of this sexually inappropriate behavior. However, the admission summary completed by that RN did not include the sexually inappropriate behavior or any interventions to address it, and there was no care plan or behavior monitoring documented in the resident’s medical record to address this risk.

Multiple observations and interviews described the events leading to and surrounding the assault. The cognitively intact roommate reported that the male resident had come into their room multiple times before the incident, made flirtatious faces at the cognitively impaired resident, and that she had yelled at him to leave. On the day of the incident, the roommate ran into the hallway and requested staff assistance. A CNA entered the room quietly, heard moaning, saw shoes and jeans at the foot of the bed, and upon pulling back the curtain observed the male resident on top of the cognitively impaired resident, with both facing each other and actively engaged in sexual intercourse; the male resident then jumped off and ran out. The cognitively impaired resident’s brief and pants were pulled down to her knees, and she curled into a fetal position and refused to talk. Subsequent hospital sexual assault examination records documented that staff and law enforcement reported the male resident was forcing penile-vaginal penetration, and the exam found brown ecchymosis on the left medial anterior labia minora, with a sexual assault kit collected and STI prophylaxis and emergency contraception provided. The male resident later told staff and hospital providers that he had intercourse because the other resident did not object and acknowledged she did not give consent.

The facility’s own policies required assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, including wandering into others’ rooms and sexually aggressive behavior, and required the IDT to identify behavioral safety risks and develop resident-centered care plans. The dietician, who reviewed the admission paperwork and saw documentation of the male resident’s sexually inappropriate behavior, added this behavior as a problem in a nutrition care plan but did not notify other staff or develop behavior-related interventions, and the care plan interventions addressed only nutritional risks. The DON and ADON later acknowledged that the admitting RN knew of the sexually inappropriate behavior and that no care plan, behavior monitoring, or enhanced monitoring of the resident’s whereabouts was implemented, and that there was no documentation that staff beyond the admitting RN and RD were aware of the behavior. This lack of interdisciplinary communication, failure to incorporate known sexually inappropriate behavior into the comprehensive plan of care, and failure to monitor and manage the resident’s wandering and sexual behavior constituted noncompliance with the facility’s Abuse and Neglect Prohibition Policy, Protection of Resident policy, Resident Safety policy, and Comprehensive Plan of Care policy, and led to the sexual assault of the cognitively impaired resident.