Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. One resident was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and was care planned for impaired cognitive function requiring supervision, reorientation, and monitoring. A 5-Day MDS documented severe cognitive impairment, and the resident’s husband reported she was confused and unable to make her needs known. There were no progress notes documenting physical or sexual abuse involving this resident on the date of the incident. Another resident, admitted with cerebral infarction, schizophrenia, and psychoactive substance abuse, had intact cognition and was ambulatory per the admission MDS. This resident’s care plan did not include any information related to sexual history or sexual behaviors. On the evening in question, a CNA witnessed this cognitively intact resident lift the cognitively impaired resident’s shirt and rub her left breast at the nurses’ station. The CNA immediately intervened, separated the residents, questioned the resident who did the touching, and reported the incident to an LPN. The resident who committed the touching denied the behavior and made a comment that the other resident should wear a bra. The facility’s self-reported incident described the CNA’s account, but the facility’s investigation ultimately concluded that no abuse had occurred, based on a belief that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator later stated he was unaware of the CNA’s written witness statement describing the breast touching. The resident’s husband reported that the administrator downplayed what had happened and that he was not informed that his wife’s breast had been touched inappropriately. Review of facility policy on abuse, neglect, exploitation, and misappropriation of resident property showed that all alleged violations of abuse were to be investigated and all witnesses interviewed, but the investigation did not fully incorporate the CNA’s eyewitness account, leading to a failure to ensure the resident was free from sexual abuse.
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