F0600

J

Failure to Protect Non-Verbal Resident From Sexual Abuse by CNA

Sedalia, Missouri Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

Facility staff failed to protect a non-verbal resident with intellectual and developmental disabilities from sexual abuse by a CNA. The resident’s MDS showed non-verbal status and diagnoses including psychological development disorders, intellectual disabilities, and developmental disorder. On the early morning in question, an LPN entered the resident’s room to administer morning medications and found the curtain drawn, which was unusual for this resident. Upon pulling back the curtain, the LPN observed the CNA and the resident lying on their right sides in the resident’s bed, with the CNA’s pants around his/her ankles and the resident’s sweatpants and underwear on the bed. The LPN reported that it appeared they were having intercourse, although he/she was not certain, and the CNA greeted the LPN when discovered.

Additional staff were summoned to the room, including an RN, another LPN, a CMT, and another CNA. When the RN arrived, the CNA had his/her pants back on and was sitting on the resident’s bed next to the resident, who remained naked from the waist down. The RN and other staff repeatedly instructed the CNA to leave the resident’s room; however, the CNA initially remained in the room and attempted to close the door. The CNA left the room, then returned again to the resident’s room while the resident was still undressed from the waist down, and was again told to leave. Staff observed that the CNA’s phone, left on the resident’s bed, had pornography pulled up. The resident was later noted pulling up his/her black slacks without assistance. Police were called, and the CNA was ultimately detained outside the facility. A SANE RN later examined the resident at the hospital and reported the resident appeared very timid and afraid to be touched, and only a limited exam could be completed.

Interviews and record review showed that the CNA admitted to law enforcement that he/she had sex with the resident prior to the nurse entering the room and stated that they were watching pornography when the nurse came in. The CNA further told the detective that he/she had been in the resident’s room from approximately 11:00 or 12:00 the previous night and had sex with the resident two or three times before, and claimed that sex was part of the resident’s daily living activities. Staffing and supervision issues during the night shift contributed to the CNA’s prolonged, undetected access to the resident. The ADON, who was the charge nurse, last saw the CNA around 1:15 A.M., could not locate the CNA afterward, and found the CNA’s phone at the nurse’s station but did not notify anyone, assuming the CNA had left and focusing on completing his/her own work. Another CNA assigned to the same hall reported that the CNA sometimes disappeared for one to two hours on previous occasions and that on this night he/she had to cover the hall alone after about 1:00 A.M., but did not report the CNA’s absence because he/she felt it was not his/her place. The CNA assigned to check residents every two hours stated he/she did not believe he/she entered this resident’s room the entire shift because he/she was busy. These actions and inactions allowed the CNA to remain alone with the resident for an extended period, during which the sexual abuse occurred.

The facility’s abuse and neglect policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, including sexual abuse, and specified that sexual abuse is non-consensual contact of any type with a resident. The CNA had previously signed an abuse and neglect acknowledgement and had a criminal background check indicating eligibility to work in LTC. Despite this, the CNA was able to enter and remain in the resident’s room for hours during the night without detection or intervention by nursing staff or CNAs responsible for monitoring residents and coworkers’ whereabouts. The failure of staff to promptly identify, report, and act upon the CNA’s unexplained absence from assigned duties, combined with the lack of timely checks on the resident, directly led to the situation in which the CNA was found in bed with the resident, both undressed from the waist down, and to the CNA’s subsequent admission of repeated sexual contact with the resident.