F0600

D

Failure to Protect Cognitively Impaired Resident From Sexualized Contact by CNA

San Antonio, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from abuse when a CNA engaged in kissing and physical contact of a sexual and unprofessional nature with the resident, as captured on video and later corroborated by the resident’s own statement. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS 11/15), anxiety, memory deficits following a stroke, left-sided hemiplegia/hemiparesis, and dependence on staff for most ADLs including toileting and transfers. Her care plan identified memory problems affecting her ability to communicate needs, cognitive impairment impacting communication, and risk for emotional distress and behaviors, with interventions focused on reassurance, monitoring for emotional issues, and speaking in a calm tone.

Video evidence from the resident’s room on the morning in question showed CNA A seated close to the resident’s bed with his right arm under the resident’s blanket near her chest while she lay in bed covered with blankets. The CNA leaned over the resident and appeared to kiss her near the head, with an audible kissing sound, while his arm remained under the blankets at her chest. In a subsequent video a few minutes later, the CNA was seen standing at the bedside holding the resident’s hand with both of his hands, then leaning down and kissing her near the side of her mouth, after which the resident said, “Thank you.” The CNA then again leaned down and kissed the resident on her mouth; the resident smiled and made a pecking sound. The CNA told the resident, “I like you,” continued to hold her hand, caressed the right side of her face several times with the back of his hand and fingers, and discussed returning later to check on her.

Record review showed that during a facility interview conducted after the incident, the resident initially responded “Yes, some man kissed me and touched me” when asked if she had ever been treated in a rough, inappropriate, or unkind manner. In a later interview with surveyors, the resident stated she had been told by administration that the CNA was only trying to console her because she was sad, and she reported that he kissed her on the forehead, denied being kissed on the mouth, and said she did not feel threatened, though she was surprised anyone would want to kiss her at her age. An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the camera footage and transmission of the video to the Administrator and DON. The Administrator acknowledged there had been previous unsubstantiated concerns about inappropriate touching with another resident and an incident of the CNA holding this resident’s hand. The DON and Administrator characterized the conduct as unprofessional and stated it was not reported to HHSC because they believed there was no allegation and the resident felt safe, despite facility policy defining sexual abuse as non-consensual sexual contact of any type with a resident and requiring all alleged or suspected violations to be promptly reported to appropriate state agencies.

Further review of CNA A’s personnel file showed he had completed competency training on privacy, dignity, resident rights, and abuse/neglect, and had been deemed competent in knowledge of abuse, neglect, and reporting. A disciplinary action was documented for rude, disrespectful, or unprofessional behavior and failure to maintain professional boundaries, categorized as a violation requiring written coaching. Time sheets confirmed that the CNA worked on the date of the incident and the following day, with no further shifts afterward. In a telephone interview, the CNA stated the resident had expressed loneliness, suicidal thoughts, and feelings of being forgotten by family, and that he hugged and kissed her on the cheek in what he described as a mutual, consoling interaction, while denying kissing her on the lips or being inappropriate. Despite these statements, the video evidence and the resident’s earlier report that a man had kissed and touched her demonstrate that the facility failed to protect the resident from abuse and failed to treat the conduct as an allegation requiring reporting and full recognition as potential sexual abuse under its own policy and regulatory definitions.

The facility’s abuse policy, revised January 2024, stated that every resident has the right to be free from abuse and neglect and that residents should not be subjected to abuse by anyone, including team members and other residents. The policy required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies per state and federal requirements. It also referenced the federal definition of sexual abuse as non-consensual sexual contact of any type with a resident and defined “willful” as deliberate action, not requiring intent to cause harm. In this case, the CNA’s deliberate kissing and intimate physical contact with a cognitively impaired, dependent resident, combined with the facility’s failure to recognize and report the conduct as an allegation of abuse despite video evidence and the resident’s statement that a man had kissed and touched her, formed the basis of the cited deficiency for failure to ensure the resident was free from abuse.