Failure to Protect Residents from Sexual and Physical Abuse by Peers
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive impairments and behavioral disorders. In one incident, a resident with severe cognitive impairment and dementia was found in her room with another resident, also severely cognitively impaired and diagnosed with schizophrenia and sexual disorders. A CNA observed the second resident touching the first resident's breasts over her clothing. Both residents were immediately separated, but neither could recall the incident due to their cognitive status. The facility's investigation confirmed the occurrence of abuse. In another event, two residents with moderate cognitive impairment and histories of behavioral issues were involved in a physical altercation. One resident struck the other twice as they passed by, prompting the second resident to grab the first resident's forearm and verbally protest. Staff intervened and separated the residents. Both residents had a documented history of hitting other residents, and staff acknowledged the physical interaction between them. A third incident involved a resident entering another resident's room and refusing to leave when asked. The resident whose room was entered responded by hitting the intruding resident's arm. This event was witnessed by an LPN, who intervened to separate the residents. The staff confirmed that the physical contact constituted abuse and acknowledged the facility's responsibility to prevent such incidents. In all cases, the residents involved had varying degrees of cognitive impairment and were unable to recall the incidents afterward.