Failure to Provide Required Supervision Resulting in Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from sexual abuse by another resident. The resident who committed the abuse had a physician's order for one-to-one (1:1) supervision due to wandering and sexually inappropriate behaviors, but was not provided with a sitter during the night shift. This lack of supervision allowed the resident to enter another resident's room and commit sexual abuse, which was discovered by a nurse responding to a scream. The nurse found the perpetrator on top of the victim, whose pants and diaper were pulled down above the knees. The incident was confirmed by multiple staff interviews and documentation. Prior to the incident, there were documented episodes of the perpetrating resident engaging in sexually inappropriate behavior, such as playing with his private area. These behaviors were observed by certified nursing assistants but were either not reported promptly to licensed staff or not documented and addressed according to facility policy. The facility's change of condition policy required that such behaviors be reported to the physician, monitored, and documented, but this was not done. The lack of timely reporting and intervention meant that no new or updated interventions were developed to prevent further incidents. The victim was a resident with severe cognitive impairment, requiring significant assistance with daily activities and supervision for safety. The perpetrator had a history of paranoid schizophrenia, violent behavior, and was HIV positive. The failure to provide required supervision and to act on prior sexually inappropriate behaviors directly led to the incident of sexual abuse. Staff interviews confirmed that the required 1:1 supervision was not in place at the time of the incident, and that there was no process to ensure compliance with sitter assignments.