Failure to Protect Resident from Sexual Abuse Due to Inadequate Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a substantiated incident of nonconsensual sexual contact. A resident with anoxic brain damage and in a persistent vegetative state, who was completely dependent on staff and unable to consent, was found by a CNA to be the victim of a sexual act performed by their roommate. The CNA observed the roommate with their head and face in the resident's private area, with the resident's incontinence brief unfastened and their private area exposed. The incident was immediately reported to the Resident Care Manager, who confirmed the resident's condition and lack of awareness or ability to respond. Prior to the incident, the roommate had a documented history of behavioral symptoms, including threatening, scratching, grabbing others, wandering, and physical aggression, as recorded in December and January. Despite these behaviors, there was no evidence that a behavioral care plan was developed or implemented to address these risks. Behavioral monitoring for the roommate was discontinued after a hospital stay and was not reactivated upon readmission, and the social services director and DON were unaware of the extent of the documented behaviors. The facility's policy required assessment and intervention for residents exhibiting behaviors towards others, but the roommate's behaviors were not addressed in their care plan. The lack of ongoing monitoring and intervention for the roommate's aggressive and inappropriate behaviors contributed to the failure to prevent the sexual abuse of a vulnerable, non-responsive resident.