Failure to Prevent Sexual Abuse Between Residents Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse, specifically sexual abuse, as evidenced by multiple documented incidents involving one resident inappropriately touching and attempting to kiss and fondle another resident. One resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and PTSD, exhibited escalating sexually inappropriate behaviors towards staff and a female peer over several days. Nursing and behavior notes detailed repeated incidents of the resident exposing himself, masturbating in common areas, and making unwanted advances toward staff, which were reported to the medical provider and Director of Nursing. Despite these ongoing behaviors, the resident was able to enter another resident's room and inappropriately touch and kiss her, including attempts to remove her clothing and touch her private areas. The female resident, who had a history of stroke, physical debility, and moderate cognitive impairment, was found by staff in distress, attempting to push the male resident away while he was touching her. Staff intervened and removed the male resident from the room, but observations after the incident revealed that one-on-one supervision was not consistently maintained as required. Interviews with staff confirmed that the male resident was not being properly supervised at all times, even after the incident, and that the female resident was visibly upset and crying following the assault. The facility's abuse policy prohibits any form of abuse, including sexual abuse, and requires an environment free from such incidents. The failure to provide adequate supervision and prevent the male resident's access to the female resident resulted in a violation of residents' rights to be free from abuse.