Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of sexually inappropriate behaviors and a diagnosis of severe traumatic brain injury grabbed another resident's shirt and upper chest area, attempting to touch her breast. Multiple staff and a dietary aide witnessed the event, and the victim reported feeling unsafe and uncertain about the perpetrator's intentions. The care plan for the perpetrator included interventions such as one-to-one staff monitoring and frequent checks, but these measures were not effectively implemented prior to the incident. In a separate incident, the same resident touched another resident's breast twice while she was assisting him with pudding. The victim, who had severe cognitive impairments and a diagnosis of dementia, reported the incident to the nursing home administrator. The perpetrator admitted to the behavior, and staff confirmed that the two residents had been interacting at the time. Prior to this event, the facility was aware of the perpetrator's history of sexual behaviors but had not implemented more restrictive interventions to prevent further incidents. Interviews with staff and residents confirmed that the facility's interventions were insufficient to prevent the abuse. The facility's abuse policy required maintaining an environment free from abuse and ensuring staff distribution and knowledge to meet residents' needs. However, the facility did not adequately identify or address the risk posed by the resident with a history of sexually inappropriate behavior, leading to repeated incidents of sexual abuse involving vulnerable residents.