Failure to Protect Residents from Sexual and Physical Abuse by a Peer
Penalty
Summary
The facility failed to protect six residents from sexual and physical abuse by another resident, resulting in multiple incidents of inappropriate touching, physical aggression, and sexualized behaviors. The resident responsible for the abuse had a history of dementia, agitation, schizophrenia, and poor impulse control, with documented behavioral issues including aggression toward other residents and staff, as well as repeated sexualized behaviors toward female peers. Despite these ongoing behaviors, interventions such as 1:1 supervision were not consistently implemented, and staff responses were often limited to redirection, which proved ineffective in preventing further incidents. Several incidents were documented in clinical records and staff interviews, including the resident physically assaulting another resident over a chair, resulting in a hairline rib fracture, and multiple episodes of inappropriate sexual contact, such as touching, kissing, and attempting to bring female residents into his room. Staff and housekeepers observed these behaviors and reported them to supervisors, but there was a lack of consistent escalation to the Director of Nursing or Abuse Coordinator. In some cases, staff did not recognize the need to report incidents as abuse, and documentation of these events was incomplete or missing from resident records. The facility's failure to ensure timely and appropriate reporting, documentation, and intervention allowed the abusive behaviors to continue, exposing vulnerable residents with severe cognitive impairments to further harm. Interviews revealed that staff were aware of the resident's unpredictable aggression and sexualized behaviors, but did not consistently implement or escalate protective measures. The facility's policies required immediate reporting and intervention for abuse, but these procedures were not followed, resulting in ongoing risk and actual harm to multiple residents.