Failure to Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse involving two male residents with severe cognitive impairment after another resident, who had a known history of sexually inappropriate behaviors, was observed engaging in potentially abusive conduct. Specifically, the resident with a history of hypersexual behaviors was seen sitting on one male resident's lap and stroking and rubbing another male resident's face. Both male residents were documented as being severely cognitively impaired and unable to consent, yet no investigation was initiated following these incidents. Staff interviews revealed that the incidents were not recognized as potential abuse, and the administrator stated that no investigation was conducted because the incidents were perceived as consensual and harmless. However, there was no documented assessment to determine the ability of the involved residents to consent or whether any harm had occurred. The facility's own policy required immediate response and investigation of alleged abuse, including assessment of the alleged victims, but these steps were not taken.