Failure to Prevent Sexual Abuse Due to Inadequate Resident Monitoring
Penalty
Summary
The facility failed to protect a resident from sexual abuse by not adequately monitoring the whereabouts of another resident who was newly admitted and alert. On the night of the incident, staff did not ensure that the male resident was accounted for, which allowed him to enter the female resident's room unsupervised. Facility policy prohibited male residents from entering female residents' rooms, but this was not enforced, and there was no system in place to monitor the new resident's movements during the night shift. The incident was discovered during a routine room check by a registered nurse, who found the male resident on top of the female resident, with her pants down and his face near her genital area. The nurse intervened immediately and separated the two residents. Interviews with staff confirmed that the female resident was confused, could follow simple commands, and was only oriented to her name, while the male resident was alert, able to make himself understood, and had no cognitive or physical impairments. Further review revealed that the facility did not have a policy or procedure for assessing or documenting consent for sexual relationships between residents, nor had an interdisciplinary team meeting or consent process been conducted for these two residents. Staff interviews indicated that abuse allegations should be reported immediately, and that new residents should be closely monitored, but these protocols were not followed in this case.