Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to recognize, document, and respond appropriately to an allegation of sexual abuse between residents. On 01/25/2026, video evidence showed a male resident (Resident #2), who had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, placing his hand between a female resident’s (Resident #1) legs and touching her private area over her pants while they were in the dining room. Resident #1 also had severe cognitive impairment with diagnoses including cerebral infarction, bipolar disorder, and memory deficit, and her care plan identified risks related to impaired cognitive function, psychosocial well-being, and re-traumatization due to a history of trauma from other resident violence. At the time of the incident, no staff were present in the dining room, as confirmed by another resident (Resident #3) who witnessed the event. Despite the allegation being reported to the Administrator by a resident witness and to the DON and Administrator by an unidentified staff member around the end of January 2026, the facility’s records for Resident #1 contained no progress notes, incident reports, or witness statements regarding the abuse allegation. The Administrator, who served as the abuse coordinator, and the DON both acknowledged being informed of an incident in which Resident #2 attempted or was alleged to have touched Resident #1 in her private area, but neither could recall which staff member reported it. When interviewed, Resident #1, who was alert and willing to speak but severely cognitively impaired, denied remembering anyone touching her inappropriately. The lack of documentation and investigation in the EMR, combined with the absence of staff supervision at the time of the incident, formed the basis of the cited failure to ensure the resident’s right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
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