Failure to Protect Residents from Sexual Abuse Due to Inadequate Interventions
Penalty
Summary
The facility failed to protect residents from sexual abuse by not developing or implementing adequate interventions to address a resident's (R2) ongoing sexually inappropriate behaviors toward other residents. R2, who had severe cognitive impairment and a history of inappropriate sexual behaviors, was observed on multiple occasions engaging in sexual acts in public areas, including masturbating and touching other residents. Despite documentation of these behaviors and staff observations, the care plan for R2 did not include specific interventions to prevent sexual abuse or protect other residents from further incidents. R2's medical history included severe cognitive impairment, difficulty walking, and behavioral disturbances. The resident was prescribed medications such as medroxyprogesterone and later Paxil to address sexual dysfunction and behavioral issues. However, there were lapses in medication administration, with missed doses of medroxyprogesterone in two consecutive months, and staff were not consistently implementing or documenting interventions to prevent R2 from having access to other vulnerable residents. Staff interviews revealed inconsistent understanding and application of monitoring and separation protocols for R2, with some staff stating they were told to keep R2 away from other residents, while others reported no specific instructions. Two other residents with severe cognitive impairment and limited mobility were directly involved in incidents where R2 was observed engaging in inappropriate sexual contact with them. In both cases, staff intervened after the incidents occurred, but there was no evidence of proactive care planning or environmental modifications to prevent recurrence. The facility's failure to identify, assess, and implement effective interventions to address R2's behaviors resulted in repeated exposure of other residents to potential sexual abuse.