Failure to Prevent Resident‑to‑Resident Sexual Incident and Staff Physical/Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an abuse‑free environment for multiple cognitively impaired residents. Facility policy on abuse, neglect, and exploitation required written procedures to prohibit and prevent abuse and to establish a safe environment, including for residents’ consensual sexual relationships and prevention of sexual abuse. Despite this, one resident with severe cognitive impairment and wheelchair dependence was found on the floor in another resident’s room, with that other resident sitting on the bed and holding the waistband of the resident’s pants and pulling downward, exposing the edge of the underwear. The doorway was partially blocked by a wheelchair, and other equipment was arranged in a crescent shape around the resident on the floor, and the resident was initially anxious. Staff reported that the resident who was pulling at the clothing was confused and did not know where they were or what they had done. Another incident involved a resident with a BIMS score of 0, indicating severe cognitive impairment and complete dependence in ADLs. A CMA reported overhearing two CNAs in this resident’s room referring to the resident in a derogatory manner. When the CMA entered the room shortly afterward, the CNAs were gone, and the resident, who usually laughed when the CMA entered, was instead tense, with their back straight and arms drawn tightly into the body. The CMA asked if the CNAs had hurt the resident, and the resident, who was rarely verbal but sometimes gave one‑ or two‑word responses, answered yes. Subsequent nursing assessment documented that the resident appeared frightened, with several small, round bruises approximately one to two centimeters in size and two crescent‑shaped skin tears on the right forearm, similar in size and shape to fingernails. A third incident involved another resident with severe cognitive impairment and dependence in ADLs. A state reportable incident documented that one CNA stated they witnessed another CNA “pop” the resident on the arm/hand after the resident hit the CNA following a change. The CNA accused of striking the resident stated they had only tapped the resident on the wrist four times because the resident allegedly grabbed them by the waist and chest. These events, involving physical and verbal mistreatment and an attempted removal of clothing from a cognitively impaired resident, occurred despite the facility’s written policy prohibiting abuse and requiring prevention of abuse, neglect, and exploitation.
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