Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from abuse, specifically sexual abuse, as evidenced by an incident in which one resident with dementia and agitation was witnessed touching the breast of another resident who was severely cognitively impaired. Multiple staff members observed the inappropriate contact in the dining room and reported that the resident who initiated the contact was verbally aggressive and resistant to redirection. Staff attempted to separate the residents and keep them apart, but the resident continued to attempt to approach the other and displayed ongoing aggressive behavior toward both staff and other residents. The residents involved had significant cognitive impairments, with one being severely impaired and the other diagnosed with dementia but assessed as cognitively intact at admission. Despite staff interventions to redirect and monitor the residents, the inappropriate contact occurred and was witnessed by several staff members. The facility's administrator acknowledged that neither resident had the mental capacity to consent to the contact and recognized the obligation to ensure residents are free from abuse. The events described indicate that the facility did not effectively prevent or protect residents from abuse as required by policy.