Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving a cognitively impaired resident with a history of trauma, including PTSD and dementia. The resident's care plan identified a potential for abuse and noted that being grabbed or observing others being grabbed were known trauma triggers. Despite these documented risks, another resident approached from behind and grabbed the resident's buttocks with both hands while both were clothed. The incident occurred in a common area and was witnessed by the resident's family, who reported it to staff. The resident expressed distress, embarrassment, and pain as a result of the incident, which occurred in front of others and triggered his trauma. Multiple staff interviews and witness statements confirmed that the incident was reported to nursing staff and administration. The resident described the event as being groped and squeezed on the buttocks, and he reported feeling terrible and embarrassed. The resident's family corroborated his account and expressed concern about the documentation of the incident by outside medical providers. The resident was sent for medical evaluation, where no physical injuries were found, and the police were contacted. There was no evidence of prior inappropriate sexual contact between the involved residents, but one resident had a history of grabbing others, though not previously in a sexual manner. The facility's abuse policy prohibits all forms of abuse and requires measures to prevent such occurrences. However, the incident demonstrated a failure to protect a vulnerable resident from sexual abuse by another resident, resulting in psychosocial harm. The event was not immediately witnessed by staff, but was promptly reported by the resident and his family, and subsequently investigated by facility administration and outside agencies.