Failure to Prevent and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, specifically involving a cognitively impaired resident with a history of high-risk sexual behavior and Alzheimer's disease. This resident repeatedly engaged in unwanted sexual advances and physical contact with other cognitively impaired residents who were unable to consent. Despite multiple incidents of inappropriate touching, including grabbing and rubbing other residents, the facility did not consistently implement or update interventions to prevent further abuse. Staff responses were limited to redirecting the resident or returning him to his room, without establishing effective ongoing measures to ensure the safety of other residents. The resident's care plan documented cognitive loss, severe memory impairment, and a risk for sexually inappropriate behaviors. Although the care plan included some interventions such as one-on-one monitoring and psychiatric evaluation, these were not consistently or effectively applied following each incident. Several incidents were not fully investigated, and there was a lack of documentation regarding notification of law enforcement or comprehensive follow-up. The facility also failed to maintain thorough investigation reports and did not always update care plans or implement new interventions after each event. Interviews with staff and administrative personnel revealed inconsistent understanding and application of abuse prevention protocols. Some staff were unaware of specific incidents, and there was confusion about when to notify law enforcement. The facility's own policy required immediate action and reporting of abuse, but this was not followed in multiple instances. As a result, cognitively impaired residents, particularly those unable to consent, were left vulnerable to repeated sexual abuse, placing them in immediate jeopardy.
Removal Plan
- The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured.
- The facility notified Law Enforcement.
- LN I received disciplinary action for failure to report the incident.
- LN F received disciplinary action for failure to report the incident.
- The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being.
- The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals.
- The facility immediately educated all staff regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations.
- The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation.
- The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone.