Failure to Protect Resident from Sexual Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia and psychosis was not protected from sexual abuse by another resident. The incident took place in the dining room, where a staff member observed a male resident, who was cognitively intact but had a history of inappropriate behavior towards female peers, sitting very close to the female resident and moving his hand back and forth over her lap. Upon intervention, the staff member noticed that the female resident's pants were unbuttoned, and the male resident quickly left the area. The staff immediately reported the incident to the nurse, who then assessed the female resident for harm and notified facility leadership. Prior to this event, the male resident's care plan had been updated multiple times to address his interest in and potential for inappropriate touching of female residents, including the same female resident involved in this incident. Despite these interventions, the incident still occurred, indicating a failure to ensure the safety and protection of the cognitively impaired resident from sexual abuse by another resident. The facility's policy states that all residents have the right to be free from abuse, including abuse by other residents.