Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident with a known history of inappropriate sexual behaviors. One resident, who was cognitively intact but physically dependent and diagnosed with multiple neurological and psychiatric conditions, reported that another resident entered their room without permission and engaged in non-consensual sexual contact. Prior to this incident, the victim had filed a grievance indicating discomfort and fear due to the perpetrator's repeated unwanted physical contact and advances, including being asked on a date and having to ask the perpetrator to stay out of their room. The perpetrator had a documented history of making sexually inappropriate comments and advances toward both staff and other residents. Multiple grievances and progress notes detailed incidents where the perpetrator made explicit sexual remarks to staff, expressed intentions to date or be physically intimate with others, and intruded into other residents' rooms. Despite these documented behaviors, interventions were limited to education and medication for sexual disinhibition, and there was no evidence of increased supervision or environmental modifications to prevent further incidents. On the day of the incident, facility camera footage confirmed that the perpetrator entered the victim's room and remained there unsupervised for approximately 30 minutes. The victim later reported the assault, describing non-consensual sexual contact that resulted in physical injury. Staff interviews and documentation revealed that the facility was aware of the perpetrator's ongoing inappropriate behaviors but did not implement sufficient measures to prevent resident-to-resident abuse, ultimately resulting in a serious incident of sexual abuse.