Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Housekeeping Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by an Environmental Services (EVS) housekeeper, in violation of its abuse, neglect, and exploitation policy, which prohibits sexual abuse defined as non-consensual sexual contact of any type with a resident. The resident involved had diagnoses including anxiety, major depressive disorder, and vascular dementia, and her most recent MDS assessments showed moderately impaired cognition with poor decision-making skills, need for cueing and reminders, and cognitive loss/dementia as an area of concern. Her care plan identified poor decision-making and required staff monitoring and redirection as needed. On the day of the incident, facility camera footage showed the resident leaving her room briefly and then returning and closing the door, with no further exit observed. Later that afternoon, the EVS housekeeper entered another resident’s room without knocking, then exited and shortly thereafter knocked on the involved resident’s door and entered, closing the door behind him. He remained in the room for approximately 12 minutes before a CNA entered the room while passing ice water. The CNA reported observing the EVS housekeeper standing with his pants down and the resident lying in bed with his penis in her mouth; the CNA stated she gasped, the housekeeper said “Oh shit,” and ran into the bathroom with a “scary look” in his eyes. The facility’s incident report documented that a staff member walked into the resident’s room and observed the staff member with his pants down and it appeared the resident was engaged in oral sex. Review of police body camera footage from the same day captured the resident stating, “My mind is gone,” and telling the Administrator and a police officer, “I am not saying I enjoyed it. He enjoyed it,” and, “It ain’t about me, it is about him.” These observations and statements, combined with the resident’s documented cognitive impairment and need for supervision, demonstrate that the facility did not ensure the resident’s right to be free from sexual assault by facility staff.
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