Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, neglect, and exploitation, specifically failing to ensure that one resident was free from sexual abuse by another resident. On the date of the incident, a resident with significant cognitive and physical impairments, including cerebral palsy, intellectual disabilities, and dependence on staff for most activities of daily living, was subjected to inappropriate sexual contact by another resident. The perpetrator, who had recently been admitted and was known to wander throughout the facility due to dementia and altered mental status, instructed the victim to touch his private parts and body. The incident was reported by the victim to the Activity Director, who then relayed the information to supervisory staff. The victim's care plan documented cognitive impairment and a need for staff assistance with most activities, while the perpetrator's care plan noted wandering behavior and risk of elopement but did not indicate any prior aggressive or sexual behaviors. The two residents were not roommates and lived on separate halls, but the perpetrator was observed pushing the victim's wheelchair and interacting with him in common areas. Staff interviews confirmed that the incident was disclosed by the victim and that the perpetrator initially denied, then later admitted to the inappropriate contact during the facility's investigation. There was no direct witness to the abuse, but the victim consistently described the incident to multiple staff and family members. Documentation and interviews revealed that the facility's staff had been trained on abuse prevention, reporting, and resident rights, and that the facility had policies prohibiting abuse and neglect. However, the incident occurred despite these measures, as the perpetrator was able to access and interact with the vulnerable resident without adequate supervision or intervention. The deficiency was identified as past noncompliance, with the incident placing all residents at risk of abuse and neglect that could result in emotional and mental trauma.