Failure to Protect Residents From Sexual and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and verbal abuse, and to correctly identify and treat certain resident-to-resident contact as sexual abuse. One cognitively intact resident with dementia and occasional confusion was found in bed with another resident who had moderate cognitive impairment and impaired decision-making. A CNA witnessed the cognitively impaired resident in the other resident’s bed kissing her on the lips and reported the incident to nursing staff. The roommate of the kissed resident reported hearing smacking noises, hearing the cognitively impaired resident ask if the other resident wanted more, and hearing laughter. The facility’s investigation documented that attempts to interview both residents and law enforcement interviews were unsuccessful due to confusion, and the facility concluded that the interaction was not sexual abuse because the residents did not appear distressed and seemed to enjoy themselves. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, but the Administrator and ADON stated they did not believe abuse occurred in this incident. The Administrator described sexual abuse as involving a resident who was upset, crying, and not wanting to be touched, and stated that both residents were capable of making their own decisions and that consent was determined by whether residents could make their needs known. The ADON acknowledged that one resident had fluctuating coherence and that the other resident had moderate cognitive impairment, yet still did not consider the incident to be abuse. The legal guardian for the cognitively impaired resident stated that this resident was not able to consent, was not capable of signing paperwork, and was not capable of making decisions, but this was not reflected in the facility’s determination that the event was not sexual abuse. The deficiency also includes an incident of staff-to-resident verbal abuse. A cognitively intact resident with multiple complex medical conditions, including end stage renal disease, Parkinsonism, liver cirrhosis, chronic pain, anxiety, seizures, and bilateral leg amputation, reported that during a smoke break he asked a Resident Care Assistant to roll his wheelchair back toward the door. The RCA refused, telling the resident that since he rolled himself out, he should roll himself back in, and called him an expletive. The resident and other residents reported that the RCA refused to assist and engaged in a verbal altercation, and the resident stated that the RCA threatened to pull him out of his wheelchair, stomp on him, and cussed at him. The RCA’s written statement confirmed that he refused to assist and used profanity toward the resident, and the facility substantiated the allegation of verbal abuse based on the resident’s account, witness statements, and the RCA’s admission.
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