Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when a male resident with a history of dementia, impaired cognition, and documented hypersexual behaviors was able to enter the room of a female resident and inappropriately touch her. The male resident had a known pattern of sexually inappropriate behaviors, including previous incidents of touching other residents and staff inappropriately, making sexual remarks, and being noncompliant with medications prescribed for hypersexuality. Despite these behaviors, the care plan interventions, such as monitoring in hallways and use of alarms, were not sufficient to prevent the male resident from accessing other residents' rooms unsupervised. On the day of the incident, staff observed the male resident wandering the halls and entering female residents' rooms. Staff redirected him to his room, but he was later found in the female resident's room, sitting at the foot of her bed with her brief undone and his hand between her legs. The female resident, who had limited mobility due to a stroke and required assistance with ADLs, was asleep at the time and did not recall the incident upon waking. Staff immediately separated the residents and notified appropriate personnel, but the incident revealed that existing monitoring and supervision measures were inadequate to prevent resident-to-resident abuse. The care plan for the female resident did not include information about the risk of resident-to-resident incidents, despite her vulnerability due to physical limitations. Interviews with other residents indicated concerns about male residents entering female residents' rooms and a perception that staff response was not always timely. The report documents that the male resident's behaviors were known to staff, and interventions such as medication adjustments and increased monitoring had been attempted, but these measures did not prevent the incident of abuse.