Failure to Protect Residents from Sexual Abuse by Known Offender
Penalty
Summary
The facility failed to protect four male residents from sexual abuse by another resident with a known history of hypersexual and inappropriate behaviors. Upon admission, the resident's family member informed staff of her history of sexually inappropriate behaviors towards men and requested specific precautions, including restricting her access to male residents' rooms and requesting male staff not provide her care. Despite this information, no care plan was developed to address or alert staff to her hypersexual behaviors. Multiple incidents occurred in which the resident engaged in inappropriate sexual contact with male residents, all of whom had moderate to severe cognitive impairment. These incidents included lying on top of a resident in his bed, kissing and touching his face, slapping another resident on the thigh/groin area, and sitting in the laps of other residents while stroking their faces. Some incidents were reported and investigated, while others were not, with facility leadership determining without proper assessment that the behaviors were consensual and caused no harm. Interviews with staff revealed that they were not informed of the resident's history of inappropriate sexual behaviors, nor were they provided with education or interventions to prevent such incidents or increase supervision. Staff members expressed that they would consider the behaviors to be sexual abuse and would have reported them if they had been aware. The Social Services Director was also not informed of the incidents, and nursing staff did not recognize or report the behaviors as abuse, failing to assess the affected residents for harm or consent.