Failure to Provide 1:1 Supervision Results in Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for a resident with a known history of wandering and behavioral issues. One resident, diagnosed with paranoid schizophrenia, violent behavior, and HIV, was assessed as having a significant risk for wandering and had a physician's order for a 1:1 sitter to provide constant supervision. Despite this order, the resident was not assigned a 1:1 sitter during the overnight shift, and there was no process in place, such as a sitter log, to ensure compliance with the order. As a result of this lack of supervision, the resident with wandering behavior entered the room of another resident who had severe cognitive impairment due to dementia, depression, and schizophrenia. The cognitively impaired resident required substantial assistance with daily activities and was unable to protect herself. During the incident, the resident with wandering behavior was found on top of the other resident, whose pants and diaper were pulled down, and he admitted to having sex with her. Staff interviews and record reviews confirmed that the 1:1 sitter was not provided as ordered, and the facility's policies required that physician orders be carried out completely and that residents be protected from abuse. The absence of a sitter and lack of monitoring directly led to the incident, which was discovered when a nurse responded to a scream and found the resident in the act. The event was reported to supervisory staff, law enforcement, and other relevant authorities.