Failure to Protect Resident from Sexual Exposure by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of dementia, major depressive disorder, and wandering behavior was subjected to sexual exposure by a neighboring resident. The incident involved the neighbor entering the resident's room, unzipping their pants, and exposing themselves, which caused the resident to become upset, cry, and express fear of being raped. The affected resident's care plan had identified a risk for abuse and included monitoring for signs and symptoms of abuse, but the incident still occurred. The resident who exposed themselves had a documented history of sexually inappropriate behavior toward roommates, female staff, and other residents, with interventions in place such as behavioral contracts, documentation of behaviors, and psychiatric evaluation as needed. Despite these interventions, the inappropriate behavior recurred, resulting in emotional distress for the affected resident. The facility's abuse policy prohibits mistreatment, neglect, and abuse by anyone, including other residents, but the policy and care plans did not prevent this incident from occurring.