Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving two cognitively impaired residents. One resident, who had a diagnosis of dementia, severe cognitive impairment, and a history of inappropriate sexual behaviors, was observed by a licensed nurse groping another severely cognitively impaired resident in a common area. The care plan for the resident with a history of sexual behaviors included instructions for staff to supervise him, monitor his behaviors, and intervene as necessary to protect others, but these interventions were not effectively implemented at the time of the incident. Staff interviews confirmed that residents with behavioral concerns were not to be left unsupervised with others, and that the resident in question required supervision due to his history. Despite documented behavioral risks and care plan interventions, the resident was able to access and inappropriately touch another resident without immediate staff intervention. Both residents involved were unable to recall the incident due to their cognitive impairments. The facility's abuse prevention policy required staff to recognize and report abuse and to manage behavioral symptoms in residents at risk, but the failure to supervise the resident as outlined in his care plan resulted in an episode of preventable abuse.