Failure to Prevent Sexual and Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual abuse by another resident and verbal abuse by staff. In the first incident, a cognitively impaired resident with dementia, Alzheimer’s disease, major depressive disorder, and a BIMS score of 3 was involved. This resident had been assessed as lacking capacity to make decisions and was dependent on others for domestic tasks and safety awareness. On the date of the incident, the resident was on the smoking patio without staff supervision during a 4 p.m. smoke break. A CNA reported hearing this resident saying "no, no, no" and then observed a male resident touching the resident’s breast with one hand while attempting to raise the resident’s shirt with the other hand. The CNA noted that there were no other residents present and no staff supervising the smoking patio at that time. The male resident involved was cognitively intact, with a BIMS score of 15 and documented capacity to make decisions. In a subsequent interview, he stated that the cognitively impaired resident had held and kissed his hand and that he did not touch her breast or shirt, although a psychiatric note later documented that he stated he felt invited and began fondling her. The facility’s five-day follow-up report stated that staff witnessed the aggressor touching the victim’s breast and that evidence suggested the allegation of sexual abuse occurred. The DON acknowledged that the dependent resident required supervision and should not have been outside on the smoke patio without supervision. The second incident involved verbal abuse of another cognitively impaired resident with traumatic brain injury, Parkinson’s disease, psychosis, no decision-making capacity, and a BIMS score of 0, indicating the resident was rarely or never understood. Early in the morning, another resident with normal cognition reported to an LVN that he had seen a CNA hovering over this impaired resident and heard the CNA tell the resident to "shut up" while the resident was crying or screaming. The witness later described hearing screams that were not the resident’s normal screams, then observing the CNA standing over the resident and repeatedly saying "shut up" before leaving the room and going to the linen cabinet. The incident was documented in an SBAR as alleged verbal abuse, and an interdisciplinary post-event note recorded that the alleged perpetrator was sent home and the resident was assessed with no injury. The administrator stated that residents should be in a safe environment at all times and free from verbal abuse. Facility policies on Abuse Prevention and Resident Rights stated that residents have the right to be free from sexual and verbal abuse and to be treated with kindness, respect, and dignity.
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