Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident in which a cognitively impaired resident was found touching the genital area of another cognitively impaired resident. The event was witnessed by a Geriatric Nursing Assistant (GNA) during her initial shift rounding, who observed one resident on their knees next to another resident's bed with the incontinence brief pulled to the side. The GNA immediately intervened and reported the incident to the floor nurse. The investigation file confirmed that the incident was substantiated as sexual abuse based on the witness account. At the time of the incident, the resident who was abused did not appear to have any injuries, but the inappropriate contact was clearly documented. The Director of Nursing and the Administrator were notified shortly after the event, and the incident was reported to both the police and the state agency. The report specifically identifies a failure to ensure that the resident remained free from abuse.