Failure to Protect Cognitively Impaired Residents From Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect two residents from sexual abuse by not ensuring they were free from non-consensual sexual contact. Resident #1, admitted in December 2014, had vascular dementia, schizophrenia, anxiety disorder, severely impaired cognition with a BIMS score of 4, was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan dated 12/22/25 documented a history of engaging in non-consensual sexual advances by others and directed that close observation levels be applied as indicated per policy. Resident #2, admitted in July 2008, had vascular dementia, schizophrenia, anxiety disorder, and severely impaired cognition with a BIMS score of 6, required set-up/clean-up assistance with personal, oral hygiene, and toileting, and ambulated independently. Resident #2’s care plan dated 1/27/26 identified dementia with memory, thinking, problem-solving, and language impairment, and directed staff not to attempt to correct statements the resident believed and to provide simple responses. On 2/9/26, a Recreation Assistant entered an elevator and observed Resident #1 sitting in a wheelchair kissing Resident #2, while Resident #2’s hand was inside Resident #1’s pants. When questioned by the Recreation Assistant, Resident #2 removed the hand from Resident #1’s pants and told the staff member to mind her business. The incident was reported to the Director of Nursing Services. The Director of Behavioral Health and Social Services later questioned Resident #2, who stated it was just a kiss. The DNS identified that both residents were conserved, unable to consent to intimate touching, and deemed the incident to be inappropriate and sexual in nature. The facility’s Abuse Policy in effect at the time stated that residents would not be subjected to abuse by anyone and defined sexual abuse to include non-consensual sexual contact of any type with a resident. Despite these policies and the known cognitive impairments and care plan directives, the residents were not adequately protected from non-consensual sexual contact, resulting in the abuse incident.
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