F0600

J

Failure to Protect Cognitively Impaired Roommate From Sexual Abuse and Inadequate Protection During Investigation

Macon, Georgia Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident (R1) from sexual abuse by his roommate (R2) and to provide adequate protection for R1 during the subsequent investigation. R1 had major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, a cognitive communication deficit, muscle weakness, and a contracture of the right hand. His admission MDS showed a BIMS score of 5, indicating severe cognitive impairment. R2 had diagnoses including insomnia, major depressive disorder recurrent severe without psychotic features, a history of non‑suicidal self‑harm, and unspecified dementia with psychotic disturbance, with a five‑day MDS BIMS score of 2, also indicating severe cognitive impairment.

On the evening of 12/20/2025, CNAs observed R2 standing at R1’s bedside with his penis out of his pants, moving his hands in an up‑and‑down motion near R1. The CNAs attempted to redirect R2 to the restroom and then to his side of the room, but he refused to enter the restroom and, after being guided back and separated by a privacy curtain, he snatched the curtain back and sat in a chair at R1’s bedside. When the LPN entered, R2 was seated on R1’s side of the room. The LPN questioned R2 about exposing himself, which he denied, and assessed R1, who denied that R2 had touched him, pulled back his covers, or touched him with his private parts. Nursing notes documented that the Administrator and DON were notified, law enforcement was contacted, and the NP was informed and initiated behavior protocol and a psychiatry referral.

Despite the facility’s written Abuse Prohibition – Reporting and Investigating policy requiring immediate response to protect the alleged victim, increased supervision of the alleged victim and residents, and possible room or staffing changes at the discretion of administrative staff, R2 remained in the same room with R1 following the incident. Hourly checks and keeping the door open with the privacy curtain pulled were implemented, but R1 and R2 continued to share the room for several days after the event. In a later interview, R1 reported that his roommate had previously sat on his bed near the foot of the bed, naked from the waist down with his penis in his hand, and that he told him to leave but did not report the incident to staff. The facility’s actions and inactions, including not immediately separating the residents and relying on hourly monitoring while both residents with severe cognitive impairment remained roommates, failed to provide the level of protection outlined in the facility’s abuse policies.