Failure to Supervise and Protect Resident from Sexual Abuse
Penalty
Summary
Facility administration failed to ensure appropriate supervision and protection of a vulnerable resident from sexual abuse. One resident with severe cognitive impairment, aggressive behaviors, and a history of wandering and inappropriate actions was not provided with consistent monitoring as ordered by physicians. Orders for 1:1 and 30-minute monitoring were inconsistently implemented and, at times, discontinued without documentation of increased or frequent monitoring, leaving the resident unsupervised for extended periods. On the day of the incident, staff observed escalating interactions between two residents, including physical contact and attempts at inappropriate proximity. Despite these warning signs, staff left the area to attend to other duties, resulting in both residents being unsupervised. When staff returned, they found the cognitively impaired resident in another resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Both residents were fully clothed, but the situation indicated inappropriate sexual contact had occurred without adequate supervision or intervention. Interviews and record reviews revealed confusion and inconsistencies in staff documentation, witness statements, and the facility's investigation process. The administration did not ensure that interventions for increased supervision were implemented for either resident following the incident, and there was a lack of clear communication and follow-through regarding abuse investigation and reporting. The failure to provide necessary supervision and to implement protective interventions created a situation of immediate jeopardy for vulnerable residents.