Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for two residents, both of whom had dementia and activated Powers of Attorney for Healthcare. One resident had a documented history of sexually inappropriate behavior, verbal and physical aggression, and wandering. Despite multiple incidents where this resident made sexual comments, was verbally and physically aggressive, and entered other residents' rooms, the facility did not consistently implement or revise interventions to address these behaviors or ensure the safety of other residents. Progress notes documented several incidents, including inappropriate sexual comments and altercations with other residents, but there was a lack of corresponding care plan updates or incident reports for these events. On one occasion, a resident was observed touching another cognitively impaired resident's breasts under her shirt. The incident was witnessed by another resident, who intervened and notified staff. Both the victim and the perpetrator had severe cognitive impairment and activated POAHCs. Prior to this event, the resident with a history of inappropriate behavior had previously been involved in similar incidents, including a prior sexual interaction with another resident and multiple episodes of aggression and boundary violations. Staff interviews revealed that these behaviors were known among staff, but documentation and communication regarding specific incidents and follow-up actions were inconsistent or lacking. The facility's policies required prompt reporting, investigation, and care plan revision following resident-to-resident altercations, especially those involving abuse or aggressive behavior. However, the facility was unable to provide evidence of investigations, incident reports, or care plan revisions for several documented incidents involving the resident with a history of inappropriate behavior. Staff and administration interviews confirmed gaps in communication, documentation, and follow-up, contributing to the failure to prevent the sexual abuse of a cognitively impaired resident by another resident with known high-risk behaviors.
Removal Plan
- Placed R2 on 1:1 supervision.
- Reviewed medical records and interviewed staff to identify other residents who may exhibit high-risk behavior.
- Developed care plans for residents identified with the potential for high-risk behavior.
- Reviewed the Abuse policy and playbook.
- Completed staff education on resident rights, abuse, reporting responsibilities, and willful/intentional acts.
- Initiated audits to ensure compliance.