Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from sexual abuse. A hospice CNA entered a male resident’s room and found a female resident sitting on his bed with her pants down to her knees and her brief pulled to the side, while the male resident’s hands were near her vaginal area. The two residents were in the male resident’s room behind a pulled curtain when discovered. This incident was reported to the Indiana Department of Health as a reportable incident. The female resident, identified as having dementia, muscle weakness, and a history of convulsions, had a quarterly MDS indicating cognitive impairment. Her care plan later documented behavioral symptoms of seeking companionship with other residents. The DON indicated that the facility initially did not think there was a concern between this resident and other residents, and that it was later determined she was seeking the male resident because he resembled her husband. Prior to that determination, the resident had been observed walking around the hallways as usual, and there were no indications in the record that she had been restricted or more closely supervised to prevent such interactions. The male resident had diagnoses including schizophrenia, psychotic disorder with hallucinations, and adult failure to thrive, and his admission MDS indicated he was cognitively intact and receiving antipsychotic medication. His care plan, developed after the incident, noted a history of schizophrenia and psychotic disorder with hallucinations and that he could exhibit behaviors including inappropriate sexual interactions with others. Written statements from hospice CNAs described the scene in his room, with the female resident partially undressed and the male resident fully dressed with his hands near her genital area. Subsequent interviews and notes documented that both residents denied that anything inappropriate had occurred, and other staff present on the unit did not report observing inappropriate behaviors between the two residents prior to the incident. Nonetheless, the observed situation in the male resident’s room constituted a failure to protect the cognitively impaired female resident from sexual abuse. Facility policies provided by the DON indicated that when a resident is accused or suspected of abuse, the facility will ensure other residents are protected, which may include increased supervision, room changes, or transfer or discharge, and that residents have the right to a safe environment. In this case, the incident occurred despite these policies, and the surveyors determined that the facility failed to ensure the female resident’s right to be free from sexual abuse was protected.
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