Failure to Prevent and Monitor Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to monitor and prevent resident-to-resident sexual abuse among several residents with severe cognitive impairments and guardianship status. Multiple incidents were documented where residents with limited or no capacity to consent were found engaging in sexual activities with other residents. In several cases, staff observed or were informed of inappropriate sexual contact, such as fondling or oral sex, but did not consistently report these incidents to the abuse coordinator or follow up to determine if proper consent had been obtained from guardians for such interactions. For example, one resident with a traumatic brain injury and severe cognitive impairment was found in another resident's room, partially undressed, with the other resident also partially undressed and fondling her. Staff had previously observed these two residents together and had redirected them, but did not seek or document guardian consent for their relationship until after the incident occurred. In another case, a resident was observed groping another resident's breasts in a public area, but the incident was not reported or documented as abuse, and there was no evidence that guardian consent for sexual activity had been obtained or clarified beyond holding hands. Additionally, there were incidents involving residents with full guardianship engaging in sexual acts, such as oral sex, where one guardian explicitly did not consent to sexual activity, only to limited physical affection like holding hands and kissing. Despite this, staff did not report the incident to the state agency, did not conduct an investigation, and did not follow up with the residents or their guardians. The facility's own abuse prohibition policy defines sexual abuse as non-consensual sexual contact of any type and requires monitoring and evaluation of residents' capacity to consent, but these procedures were not followed in the documented cases.
Plan Of Correction
F600 Free from Abuse and Neglect Resident #101 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #102 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is responsible for sustained compliance.