Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident from sexual abuse by another resident. The resident who was abused had a history of cerebral infarct, anxiety, depression, altered mental status, substance use disorder, and aphasia, and required assistance with personal care, including one-person assist for transfers, dressing, hygiene, and bathing, and two-person assist for toileting. Her MDS reflected moderately impaired decision-making, and the Nursing Home Administrator (NHA) confirmed she was not able to consent and that her responsible party did not want her to have contact with the male resident involved. Despite this, the male resident, who was cognitively intact and independent with care needs, was observed engaging in physical contact with her. Prior to the incident that led to the citation, the abused resident’s mother, who was her DPOA, had observed her daughter holding hands with the male resident in his room and reported feeling uncomfortable. She communicated to the NHA that she did not want the male resident touching her daughter for any reason. The facility’s own investigation documented that the male resident had been counseled that the female resident was unable to consent to physical touching and that her mother did not want physical contact between them. The male resident verbalized understanding. There were also prior documented behaviors by the male resident involving inappropriate touching of other residents, including touching another resident’s dorsal hand and arm, requiring redirection and behavioral monitoring. On the date of the incident, a CNA reported rounding on the unit and observing the cognitively impaired female resident in the male resident’s room. The CNA witnessed the male resident standing over her, kissing her neck, with his hand on her inner thigh by the vaginal area over her pants, groping her. The CNA immediately intervened, separated the residents, and removed the female resident from the room while telling the male resident he could not engage in that behavior. The male resident laughed, became angry, raised his voice, and began slamming items in the room. Nursing staff were notified, and documentation reflected that the contact left a red mark on the female resident’s neck. The facility’s investigation concluded that non-consensual physical contact occurred with a resident who lacked capacity to consent, and that the male resident had previously been educated not to touch her, yet still engaged in the behavior, resulting in substantiated sexual abuse. Additional documentation and interviews highlighted inconsistencies in staffing records related to who was present on the unit at the time of the incident. The CNA who reported witnessing and intervening in the abuse was not listed on the facility’s working schedule for that shift, even though both the CNA and an LPN described that CNA as being on the floor and directly involved in responding to the event. The facility schedule showed only two CNAs scheduled for the shift on the second floor, and the NHA initially stated the schedules provided were accurate. This discrepancy in staffing records was identified during the surveyor’s review of the incident and related interviews.
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