Failure to Prevent Sexual Abuse Due to Inadequate Supervision and Medication Management
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with a history of wandering and behavioral disturbances entered another resident's room and engaged in inappropriate sexual contact. The facility did not follow its Abuse and Neglect Prohibition Policy, which required identifying, correcting, and intervening in situations where abuse was more likely to occur. Staff were aware that the resident with behavioral issues frequently wandered into the same room and required frequent redirection, but adequate supervision and intervention were not provided to prevent the incident. The resident who committed the abuse had diagnoses of severe dementia with behavioral disturbance, schizophrenia, and bipolar disorder, and was known to have fluctuating capacity for decision-making. This resident had a documented history of refusing prescribed medications, including donezepril and quetiapine, which were intended to manage dementia-related behaviors and wandering. Despite repeated refusals, there was no documentation that the physician was notified, nor were alternative interventions or changes to the care plan implemented. Staff interviews confirmed that medication refusals were not properly communicated or addressed, and that the resident's wandering and behavioral episodes increased during the period of non-compliance. Observations and interviews revealed that the resident was frequently unsupervised while wandering the facility in a wheelchair, and staff had previously observed the resident entering the same room multiple times. The roommate of the abused resident also reported that the resident had been coming into the room repeatedly for several months. The facility's policies on wandering behavior management and abuse prevention were not followed, as interventions and supervision were insufficient to prevent the incident of sexual abuse.