F0600

J

Failure to Protect Cognitively Impaired Residents From Sexual Abuse and Inadequate Consent Assessment

Dunkirk, Indiana Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from sexual abuse by not adequately assessing capacity to consent to sexual activity and not implementing effective interventions for a resident with known sexually inappropriate behaviors. Resident B had diagnoses including unspecified dementia, major depressive disorder, and a cognitive communication deficit, with an MDS showing moderate cognitive impairment and moderate impairment in decision-making for daily tasks. Her care plans addressed impaired cognition, poor safety awareness, and impulsiveness, and she used a position change alarm due to attempts to self-transfer. A care plan for promotion of safe intimate/sexual practices, created shortly before the incident, stated she was alert, aware, and coherent in choosing to engage in an intimate/sexual relationship and included interventions such as assessing her understanding of the nature of the act and her ability to refuse, encouraging appropriate touch, and reminding her that sexual partners must be able to provide mutual consent. Her representatives were notified that she was seeking companionship with a male resident and agreed to hand-holding and companionship, but they did not agree to more intimate acts.

Resident C had diagnoses including unspecified dementia with behavioral disturbance and delusional disorders, with an MDS indicating severe cognitive impairment. His record documented a history of inappropriate personal boundaries manifested by inappropriate touching, such as rubbing another person’s back, reaching for a leg, and shoulder rubbing. He had been treated with medroxyprogesterone for hypersexuality and was also on risperidone. Behavior notes and staff interviews described increased friendliness and physical contact with multiple female residents, including patting arms, hand holding, rubbing arms and legs, and entering female residents’ rooms, sometimes becoming agitated or hostile when redirected. Staff, including a housekeeper and an RN, reported that he had been seen with his penis exposed in a lounge, asking a female resident to put her hands in his pants, pulling a female resident’s hand toward his genital area over clothing, and touching a female resident’s breast. Despite this pattern, his care plan for inappropriate personal boundaries was resolved, and the Social Service Director and DON indicated that, after discussions with the Ombudsman, care plans regarding sexual behaviors were resolved based on the view that such behaviors were residents’ rights rather than maladaptive behaviors.

On the evening of 3/22/26, a Qualified Medication Aide observed Resident C in Resident B’s room with his pants partially down, exposing his buttocks, while Resident B, seated in her recliner and leaning forward, was performing oral sex on him. Resident B’s roommate was in the hallway at the time. The QMA instructed Resident C to leave; he became angry but complied. Resident B said little and, after the incident, had forgotten that anything had occurred. Subsequent nursing documentation noted that Resident B would not or could not discuss the incident, described the male resident as a friend, and denied unwanted touching. Interviews with Resident B’s representative indicated that Resident B had moderate to severe dementia, sometimes did not recognize family, frequently asked where she was and when she was going home, and that performing oral sex was not consistent with her prior behavior or values. Resident B later demonstrated significant disorientation, unable to state where she was, what town she was in, or the year, and denied having a male friend or male visitors in her room.

Additional interviews and records showed that staff were aware of Resident C’s ongoing sexually focused behaviors and the need for redirection. Behavior notes shortly before the incident documented increased agitation and interactions with female peers, his anger when asked to visit females only in public areas, and an episode of inappropriate behavior with a confused female resident from whom he was redirected. The Psychiatric NP reported that the facility had been concerned about Resident C’s sudden focus on female residents and that he had required medication to prevent escalation of inappropriate touching. The NP also stated that staff had to redirect Resident C several times related to female residents and that he became agitated when redirected. The acting Administrator acknowledged that a Sexual Consent Capacity Assessment was not completed for the residents prior to the incident and that behavior documentation was only maintained if behaviors were considered maladaptive. The surveyors determined, using the reasonable person concept, that this failure to assess capacity to consent and to implement interventions to mitigate Resident C’s sexually inappropriate behaviors resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B.

Other residents and staff expressed concerns related to Resident C’s behaviors. A cognitively intact resident reported hearing from staff and in the hallway that a female resident had performed oral sex on Resident C and expressed fear that he might enter her room and touch her, stating she did not want to be touched. The Social Service Director described Resident C as social with many female residents, with hypersexuality increasing as he formed more relationships, and acknowledged that staff struggled to distinguish between appropriate social interaction and infringement on residents’ rights. Several residents, including Residents F and E, had histories of dementia and prior care plans for inappropriate personal boundaries that were later resolved, and some had care plans for companionship with male peers that included general interventions such as assessing understanding and ability to refuse, but the records lacked individualized monitoring and interventions specifically addressing intimate or sexual behaviors for all involved residents. The combination of Resident C’s known sexually inappropriate behaviors, his severe cognitive impairment, Resident B’s moderate cognitive impairment and poor memory, the absence of a formal sexual consent capacity assessment prior to the incident, and the lack of sustained, effective behavioral interventions for Resident C led to the cited deficiency for failure to protect residents from sexual abuse.

The surveyors concluded that the facility failed to ensure residents were protected from sexual abuse when Resident B, with moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. They found that the facility did not assess the residents’ capacity to consent to sexual activity prior to the incident and did not implement interventions to mitigate Resident C’s sexually inappropriate behaviors. Using the reasonable person concept, they determined that this deficient practice resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B.