Failure to Protect Resident from Sexual Abuse and Inadequate Response
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. On the day of the incident, a resident with a history of depressive disorder, schizophrenia, and cognitive decline was sitting in her wheelchair in the hallway when another resident touched her inner thigh and later placed his hands inside her shirt to touch her upper back. Multiple staff members witnessed the inappropriate touching, but the residents were not immediately separated, and both were subsequently taken to the same group activity in the Activities Room. The affected resident expressed feeling scared and unsafe following the incident, especially given her history of sexual trauma prior to admission. Staff interviews and record reviews revealed that there was no documentation of the incident in either resident's chart, including the absence of an SBAR, progress notes, care plan, or 72-hour monitoring. The physicians and responsible parties for both residents were not notified, and there was no evidence of assessment or intervention for emotional distress immediately following the event. Staff members acknowledged that the residents should have been separated and that the incident should have been reported and documented according to facility policy, but these actions were not taken. Further investigation uncovered that the resident who committed the abuse had a known history of inappropriate sexual behavior, including touching himself and making female residents uncomfortable during group activities. Despite this, there was no care plan or documentation addressing his behavior, and staff responses to his actions were inconsistent and inadequately communicated to leadership. The facility's policies for abuse prevention, reporting, and resident protection were not followed, resulting in the resident experiencing sexual abuse and ongoing emotional distress.