Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a known history of exchanging money for sex while residing at the facility. On the evening of the incident, the resident with a history of sexually inappropriate behavior entered the victim's room without consent, exposed himself, and engaged in non-consensual sexual contact, including touching and sucking on the victim's breasts, despite the victim repeatedly telling him to stop. The victim was unable to consent to sexual activities due to her mental health condition, which included paranoid schizophrenia and a legal conservatorship indicating incapacity to make her own decisions. Prior to the incident, there were documented indications that the perpetrator had been sexually active with multiple residents and had exchanged money for sexual favors. This information was recorded in progress notes and reported to a director who was no longer employed at the facility, but the DON and other key staff were not made aware of these behaviors. The facility did not investigate the allegations of money exchange for sex or the ongoing sexually inappropriate behavior, and staff were unaware of the extent of the perpetrator's actions until after the incident occurred. Interviews and record reviews revealed that staff, including CNAs and RNs, had observed or were aware of a prior relationship between the two residents, but there was no evidence that the facility assessed either resident's capacity to consent to sexual activity or implemented appropriate supervision or interventions to prevent abuse. The facility's policies prohibited abuse, mistreatment, and exploitation, and required immediate reporting and investigation of any allegations or suspicions of sexual abuse, but these procedures were not followed, resulting in the resident experiencing sexual abuse and emotional distress.