Failure to Protect Resident from Sexual Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when the facility failed to protect a female resident with a history of anxiety disorder, depression, and recent joint replacement from abuse, specifically unwanted sexual exposure by another male resident with severe cognitive impairment and a history of wandering. The female resident reported that the male resident entered her room in a wheelchair and masturbated in front of her. She disclosed the incident to multiple staff members, expressing distress and fear. Documentation in her progress notes confirmed her reports of the male resident's behavior on two consecutive nights. Despite the resident's reports, the staff response was inadequate. A CNA who received the allegations reported them to an LVN on at least two occasions, but the LVN dismissed the concerns, attributing them to confusion and did not escalate the report to facility leadership as required. The LVN did not speak to the resident about the allegations or initiate any investigation, and there was no immediate notification to the administrator or abuse coordinator. The incident only came to the attention of facility leadership after a third-party professional discovered documentation of the event during a chart review, significantly delaying the facility's awareness and response. The male resident involved had a documented history of chronic wandering and was previously observed engaging in sexually inappropriate behavior in a communal area. However, there was no evidence that the facility implemented additional behavioral interventions or supervision in response to these behaviors prior to the incident. The facility's policies required prompt investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a failure to ensure the resident was free from abuse and to report the incident in accordance with federal guidelines.