Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident with moderate cognitive impairment. The resident who was unable to consent to sexual activity had a history of aggressive behaviors, severe cognitive deficits, and required significant assistance with personal care. Despite documented behavioral issues and a care plan noting inappropriate sexual advances, the facility did not implement or maintain adequate supervision or interventions to prevent inappropriate contact between the two residents. On the day of the incident, staff observed escalating physical interactions between the two residents, including hand-holding and attempts at physical closeness, but only provided verbal redirection and did not increase supervision. Both residents were left unsupervised for a period, during which time staff later found the resident with severe cognitive impairment in the other resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Documentation revealed that orders for increased monitoring had been discontinued prior to the incident, and there was no evidence of frequent or one-on-one supervision in place at the time of the event. Following the incident, it was noted that care plans and interventions for both residents were not updated in a timely manner to address the risk of further inappropriate contact. The facility's policies required immediate intervention and protection in cases of suspected abuse, but staff interviews and record reviews indicated that administrative follow-up and investigation were delayed. The lack of prompt and effective interventions created an ongoing risk for abuse of the resident and potentially other vulnerable residents.