Failure to Implement Abuse Prohibition Policy Resulting in Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy and Procedure to prevent, prohibit, and investigate allegations of sexual abuse, specifically in the case involving two residents. One resident, who lacked the capacity to consent to sexual activities and was under a conservatorship, was subjected to non-consensual sexual contact by another resident with a known history of exchanging money for sex within the facility. Despite documentation and staff awareness of the perpetrator's sexually inappropriate behaviors and history, the facility did not take adequate steps to prevent further incidents or investigate prior allegations of exploitation and abuse. The incident occurred when the resident with a history of sexually inappropriate behavior entered the room of the resident lacking capacity, exposed himself, and engaged in sexual acts despite being told to stop multiple times. The victim reported feeling objectified and devalued as a result of the assault. Staff interviews and record reviews revealed that the perpetrator had previously been sexually active with multiple residents and had exchanged money for sexual favors, but these behaviors were not properly reported or investigated by facility leadership, including the DON and administrators. Documentation showed that staff, including a program counselor, were aware of the perpetrator's actions and had reported them to a former director, but the information was not escalated to the DON or administrator as required by policy. The facility's policies clearly defined non-consensual sexual contact and mandated immediate reporting and investigation of any allegations or suspicions of abuse. However, the facility failed to follow these procedures, resulting in the occurrence of sexual abuse and the lack of protection for vulnerable residents.