Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in significant deficiencies. One resident, who was cognitively intact and required assistance with incontinence care, reported being sexually abused by a Certified Nursing Assistant (CNA) on multiple occasions during personal care. The resident described inappropriate sexual touching, including the CNA using his gloved hand and fingers on her vaginal and rectal areas, causing pain and discomfort. The resident stated that these incidents occurred after she no longer had a roommate and that she initially did not report them out of fear, but ultimately disclosed the abuse to her family after the most recent incident. A hospital sexual assault examination confirmed trauma consistent with the resident's account, and the resident decided to pursue criminal charges. The CNA denied the allegations, but facility records confirmed he was assigned to care for the resident on the relevant dates. Another deficiency involved the facility's failure to protect a resident from physical abuse by another resident. The aggressor, who had dementia and a schizoaffective disorder, exhibited confusion and aggressive behaviors, including two documented incidents in which he physically assaulted another resident in the dining room. Witnesses, including CNAs and an LPN, observed the aggressor striking the other resident in the head and being nonredirectable during the altercations. The assaulted resident, who also had dementia and was confused, was unable to recall the incidents due to her cognitive impairment. The aggressor was transferred to the hospital for his behavior after both incidents, and staff reported that loud noises or agitation appeared to trigger his aggression. Both residents involved in these incidents had care plans indicating they were at risk for abuse and trauma. The facility's policies outlined procedures for abuse prevention, identification, and management, but the events described demonstrate that these measures were not effectively implemented to prevent abuse. The facility's investigation reports characterized the resident-to-resident altercations as accidental, but staff statements and care plans indicated a pattern of aggressive behavior and risk factors that were not adequately addressed.