Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two residents, one of whom had a documented history of sexually inappropriate behaviors. The incident occurred in the dining room, where a staff member observed a resident placing their hand under another resident's shirt and rubbing their breast area. The staff member intervened immediately, separated the residents, and reported the incident to the charge nurse. Prior to this event, the resident with a history of inappropriate behaviors had previously been involved in similar incidents, including touching another resident inappropriately and being redirected by staff. Despite these prior incidents, the care plan for this resident did not include interventions to prevent further sexually inappropriate behaviors. The resident with the history of inappropriate behaviors had multiple diagnoses, including cognitive impairment, psychiatric conditions, and sexual dysfunction. Medical records indicated that this resident had previously been prescribed medication for sexual dysfunction, which was later discontinued. The resident required substantial to maximal assistance with activities of daily living and had a moderate cognitive impairment. The other resident involved in the incident was severely cognitively impaired, dependent on staff for daily activities, and had a history of dementia and other medical conditions. This resident reported feeling uncomfortable during the incident, and a skin assessment showed no visible injury. Staff interviews revealed that several staff members had noticed the resident with a history of inappropriate behaviors showing increased attention to the other resident, such as bringing coffee, sitting close, and touching their hair. However, these behaviors were not recognized as concerning by some staff, and there was no documentation of increased monitoring or specific interventions to address the risk. The Director of Nursing confirmed that there was no clear documentation of monitoring or interventions in place to protect other residents prior to the incident.