Failure to Supervise Cognitively Impaired Residents With Known Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse when a male dementia resident engaged in sexual contact with a female dementia resident’s breast in the dining room. The incident occurred when the female resident, who had a documented history of socially inappropriate and sexually oriented behaviors, including objectifying males and making crude sexual remarks, was left unsupervised with the male resident in the dining room. Her behavior care plan, in place since 2015, specifically identified her lack of boundaries, sexually oriented comments, and gestures, and included an intervention that unsupervised visiting with male residents should be discouraged and prevented when possible. Despite this, staff allowed her to remain in the dining room with a male resident without continuous supervision before the meal was served. The male resident also had a behavior care plan for socially inappropriate behavior, including flirtatious behavior toward a peer, and had diagnoses of dementia, major depressive disorder, and anxiety disorder, with documented poor insight and judgment and significant cognitive deficits. Both residents had psychiatric evaluations indicating they were oriented only to person, with significant short- and long-term memory deficits and impaired attention and concentration. The psychiatric nurse practitioner and LCSW stated that neither resident had the decision-making capacity to consent to sexual activity or make informed decisions. The facility’s own Sexual Abuse Prevention and Management of Sexual Behaviors policies defined sexual abuse as non-consensual sexual contact and stated that consent cannot be given if a resident is cognitively impaired, and that the facility must intervene when one or both individuals lack the ability to provide informed consent. On the day of the incident, a dietary aide entered the dining room while setting up for lunch and observed the male resident sucking on the female resident’s breast after she had lifted her shirt. The aide reported that no other staff were present in the dining room at that time and that security footage showed the two residents making inappropriate contact whenever staff left the dining room and stopping when someone entered. A CNA confirmed that she had placed drinks and seen the two residents sitting together, then left the dining room before food arrived, leaving no staff present. Multiple staff interviews showed that staff were aware the female resident could be sexually inappropriate, made sexual comments, and asked other residents to perform sexual acts, but CNAs reported they were unaware of any special interventions beyond separating her when she made inappropriate comments, and that continuous monitoring of the dining room only occurred once meals were served. The abuse coordinator and regional nurse consultant later stated they believed sexual abuse was unsubstantiated because both residents appeared to enjoy the act, despite the facility’s policies and professional assessments that cognitively impaired residents could not provide informed consent.
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