F0600

E

Failure to Prevent and Adequately Address Resident-to-Resident Sexual Contact

Choctaw, Mississippi Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse by not preventing resident-to-resident inappropriate sexual contact and not providing effective supervision in common areas. Facility policy on Resident Rights, revised 3/24, states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Despite this policy, two separate incidents of non-consensual touching occurred between residents in common areas where supervision was ineffective.

In the first set of incidents, one resident with borderline intellectual functioning and a BIMS score of 7, indicating severe cognitive impairment, inappropriately touched another resident with a cognitive communication deficit. On one occasion in the front lobby, the cognitively impaired resident approached the other resident and touched her leg without consent. The affected resident reported that she told him to stop and he left her alone, and she informed staff shortly after the incident. She stated that a nurse spoke with her once about what happened, but there was no further follow-up discussion or additional inquiries from other staff, and she did not receive updates on the outcome of the investigation. A later nurse’s note documented that a female resident reported this same resident inappropriately touched her twice on her leg and between her thighs, again requiring staff intervention to separate the residents. The affected resident later expressed concern that the alleged perpetrator’s name remained on the room across from hers and reported that she planned to avoid him and common areas if he returned.

In the second incident, another resident with a cognitive communication deficit and a BIMS score of 13, indicating cognitive intactness, was observed and reported to have engaged in inappropriate touching of other residents. A health status note documented that this resident had previously been noted touching another resident inappropriately at the nurses’ desk and did not respond to redirection. Subsequently, a resident with vascular dementia and a BIMS score of 8, indicating moderate cognitive impairment, reported that this same resident touched her breasts without consent in the hallway in front of the nurse’s station. She immediately notified a CNA and clearly described that the resident had touched her breasts. The facility’s investigation, including review of camera footage, confirmed that the resident touched her breast while passing her in the hallway. Record review and interviews revealed that in both sets of incidents, the residents were in common areas without effective supervision at the time of the events, and although staff responded after the incidents occurred, the facility did not implement sufficient interventions to prevent the inappropriate resident-to-resident contact prior to the incidents.

Interviews with the LNHA and the social worker further described gaps in the facility’s response related to the affected residents’ ongoing needs after the incidents. The LNHA acknowledged that while the facility determined that inappropriate contact had occurred and that staff responded once the incidents were reported, there were areas where the response could have been improved for the affected residents. She stated that the facility should have implemented more consistent and ongoing follow-up with the affected residents, including routine check-ins to assess fear, anxiety, or other psychosocial effects, and stronger communication with them regarding the protective measures in place. The social worker similarly acknowledged that the affected residents should have received more focused follow-up and supportive services after the allegations were made, including assessment of their immediate emotional and psychological needs, private discussions, validation of their concerns, and ensuring they felt heard. These statements, combined with the lack of documentation of the inappropriate touching in at least one resident’s health status note, demonstrate that the facility did not fully carry out its responsibility under its own Resident Rights policy to ensure residents were protected from abuse and that their concerns were adequately addressed.

Record review confirmed that in both incidents, the residents were in common areas without effective supervision at the time of the events. Although staff separated residents and assessed for injuries after the incidents were reported, the facility failed to implement sufficient preventive interventions and supervision to stop the inappropriate resident-to-resident contact from occurring in the first place. The combination of ineffective supervision in common areas, repeated inappropriate touching by certain residents, incomplete documentation of the incidents in the affected residents’ records, and limited follow-up and communication with the affected residents led to the deficiency in protecting residents from abuse and ensuring their right to a safe and secure environment as required by facility policy.