WASHINGTON TERRACE, UT - Federal inspectors cited Stonehenge of Ogden for failing to properly investigate the consent capacity of two cognitively impaired residents who were repeatedly found undressed together, violating the facility's own abuse prevention policies.
Inadequate Response to Vulnerable Resident Situation
The June 27, 2024 inspection revealed that facility staff discovered residents 151 and 13 in bed together without clothing on February 15, 2024, but failed to conduct the required formal assessment of their ability to consent to intimate contact. Both residents had severely impaired cognition with Brief Interview of Mental Status (BIMS) scores of 7, indicating significant cognitive deficits.
According to inspection records, a nursing assistant found the residents "under the blankets" in a state of undress at 6:30 PM. The male resident, 151, reportedly told staff he "wants to be left alone with her" and requested staff leave immediately. Later that evening, staff noted he was seeking female residents "to meet his needs."
The facility's Social Service Worker told inspectors that while she interviewed both residents, "no formal assessment was done to determine if resident 13 was able to consent to have a relationship." The worker stated she "figured that the residents were both adults and they could consent to have a relationship with each other."
Medical and Cognitive Concerns
Resident 151 had multiple serious conditions including vascular dementia with agitation, bilateral leg amputations below the knee, and carotid artery disease. His care plan documented paranoid thoughts and delusions, including beliefs about "having bed made overseas that will grow his legs back."
Resident 13 suffered from age-related osteoporosis, diabetes, malnutrition, depression, and had paranoid thoughts believing "someone is trying to hurt me or do bad things to me." Both residents required extensive cognitive support due to their severe impairments.
Cognitive assessments using standardized tools like the BIMS are critical for determining a person's capacity to make informed decisions about intimate relationships. A score of 7 indicates severe cognitive impairment that typically affects judgment, understanding of consequences, and ability to provide informed consent.
Pattern of Concerning Behavior
The inspection documented multiple incidents suggesting the male resident's behavior was becoming increasingly inappropriate:
- May 4, 2024: Staff noted he was "headed looking for a female resident 'to meet his needs'" - Same evening: He asked staff "if he can 'have a little sex'" during medication administration - Care plans were initiated for aggressive behavior and "special friend" relationships
Despite these warning signs, facility leadership failed to implement proper safeguards or conduct thorough evaluations of both residents' cognitive capacity.
Policy Violations and Required Protections
The facility's own abuse prevention policies require immediate investigation of any suspected inappropriate conduct and mandate that staff "document and report abuse, sexual abuse and sexual exploitation" and "cooperate fully in any resulting investigation."
Federal regulations require nursing homes to protect residents from abuse, neglect, and exploitation. This includes ensuring that residents with cognitive impairments are not taken advantage of in intimate situations they may not fully understand or be able to consent to.
When residents have severe dementia or other cognitive impairments, facilities must conduct comprehensive assessments involving medical professionals to determine decision-making capacity. This process should include:
- Medical evaluation by physicians familiar with the residents - Psychological or psychiatric assessment when appropriate - Family notification and involvement in decision-making - Documentation of the assessment process and findings - Ongoing monitoring of the situation
Investigation Gaps
The Director of Nursing told inspectors that "it would be the physician that would make the decision if a resident was able to give consent," but neither she nor the Social Service Worker could recall if the medical director was ever notified of the relationship.
The facility's response was limited to informal conversations with both residents, who denied inappropriate conduct and claimed they were "just watching movies." However, inspection records show the Social Service Worker acknowledged that both residents "were confused" and that it was reported to her that they "may have been unclothed at some point."
Professional Standards and Best Practices
Industry standards require facilities to have clear policies for addressing intimate relationships between residents, particularly when cognitive impairment is involved. These policies should outline:
- Procedures for assessing capacity to consent - Medical and psychiatric evaluation protocols - Family notification requirements - Staff training on recognizing signs of potential exploitation - Documentation and reporting procedures
The facility's failure to follow these protocols created a situation where vulnerable residents with severe cognitive impairments were potentially placed at risk. Resident 151 passed away on May 19, 2024, before the investigation was completed.
Regulatory Response and Oversight
The citation was issued under F607, which addresses facilities' obligations to develop and implement policies preventing abuse, neglect, and theft. The violation was classified as having "minimal harm or potential for actual harm" affecting "few" residents.
However, the failure to properly protect cognitively impaired residents represents a serious gap in safeguarding vulnerable individuals who depend on professional caregivers to protect their wellbeing and dignity.
Facility Obligations Moving Forward
Stonehenge of Ogden must now develop and implement comprehensive policies addressing intimate relationships between residents with cognitive impairments. This includes establishing clear protocols for capacity assessment, medical evaluation, and family involvement in decision-making processes.
The facility must also provide staff training on recognizing signs of potential exploitation and ensure all incidents involving vulnerable residents are properly investigated according to federal regulations and facility policies.
Families considering placement at Stonehenge of Ogden should inquire about the facility's current policies for protecting cognitively impaired residents and ensuring appropriate safeguards are in place for vulnerable individuals requiring long-term care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonehenge of Ogden from 2024-06-27 including all violations, facility responses, and corrective action plans.
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