Failure to Supervise Residents with Known Sexual Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse and inappropriate contact between two residents, both of whom had documented histories of sexually inappropriate behaviors and cognitive impairments. One resident, with moderate cognitive impairment and a history of sexually inappropriate advances toward others, was care planned to require supervision at all times and interventions to prevent inappropriate interactions. Despite these documented needs, the resident was able to be alone in her room with another resident, who also had a history of sexual inappropriateness and severe cognitive impairment. Staff discovered the two residents in a compromising position, with both partially undressed and the male resident on top of the female resident. Prior to the incident, both residents had exhibited repeated sexually inappropriate behaviors, including attempts to enter other residents' rooms, inappropriate touching, and making sexual advances toward peers and staff. These behaviors were documented in clinical records and care plans, and staff were aware of the risks associated with both individuals. Staff interviews revealed that the only directive given was to attempt to keep the two residents apart, but no additional supervision or specific interventions were implemented, despite the known risks and previous incidents. Staff also reported difficulty in providing close supervision due to staffing levels and the residents' ability to move independently and quickly. The lack of clear directives and insufficient supervision allowed the two residents to be unsupervised together, resulting in the observed incident. The facility's failure to implement effective interventions and provide adequate supervision, as outlined in the residents' care plans and based on their behavioral histories, directly led to the deficiency. The administration and nursing leadership acknowledged that the facility did not provide adequate nursing supervision or specific instructions to staff to prevent such incidents, despite being aware of the residents' behaviors.