Failure to Protect Resident from Sexual Abuse and Inadequate Response
Penalty
Summary
The facility failed to protect a cognitively impaired resident from repeated sexual abuse by another resident who was cognitively intact. On two separate occasions during breakfast, staff observed the perpetrating resident sitting next to the victim, with their hand between the victim's legs, touching the victim's vagina. Despite staff intervening and verbally instructing the perpetrator to stop, the inappropriate contact recurred within a short period. The staff reported the incident to the Administrator in Training, who did not come to the facility, did not provide guidance, and did not implement safety interventions to prevent further abuse. The victim was severely cognitively impaired, nonverbal, and had diagnoses including cerebral palsy, intellectual disabilities, anxiety, and depression. The victim's care plan did not include interventions to prevent sexual abuse, and there was no documentation or assessment of the victim following the abuse. Additionally, a trauma care assessment was not completed after the incident, and the victim's guardian was not notified of the allegation. The perpetrator's care plan also lacked interventions addressing sexual behaviors, and there was no documentation of the abuse allegation in the perpetrator's medical record. The facility's abuse prevention policy required immediate steps to prevent further abuse, assessment of the resident, notification of the physician and responsible party, and completion of a trauma-informed care assessment. These steps were not followed after the incident, as the staff did not receive direction from administration, and the required assessments and notifications were not completed. This failure resulted in an Immediate Jeopardy situation due to the lack of protection and appropriate response to resident-to-resident sexual abuse.