Failure to Protect Residents from Sexual and Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual and verbal abuse by another resident, resulting in several incidents of resident-to-resident abuse. Specifically, a male resident with a history of schizoaffective disorder, cognitive communication deficits, and boundary issues was observed kissing two female residents who were unable to consent due to severe and moderate cognitive impairment. Staff members, including an LPN, CNA, and PA, directly witnessed these incidents and reported them to the facility administrator. Despite these reports, no incident or accident reports were completed for the involved residents, and the administrator determined that the incidents did not require reporting to the State Agency, citing his own assessment that the contact was welcome, which was not supported by staff witness statements. The affected residents included individuals with significant cognitive impairments and trauma histories, making them particularly vulnerable. One resident had a BIMS score indicating severe cognitive impairment and a care plan noting risks related to mood and behavioral disturbances. Another resident had a moderate cognitive impairment, a history of trauma, and a care plan specifying a preference for female-only caregivers. Both were unable to recall or report the incidents, and social work notes indicated the need for ongoing monitoring due to their vulnerability. Additionally, another cognitively intact resident reported feeling uncomfortable and altering her dining habits due to the perpetrator's behavior, while another resident reported being verbally abused and emotionally distressed by the same individual. The facility's abuse prevention policy required immediate reporting, investigation, and protection of residents from abuse, including resident-to-resident incidents. However, the facility did not follow these procedures, as evidenced by the lack of documentation, failure to report to the State Agency, and insufficient protective interventions. Staff interviews revealed concerns about the administrator's handling of the situation, including the removal of a social work note describing the incident as sexual assault and the lack of appropriate response to repeated abusive behaviors. The failure to act in accordance with policy and regulatory requirements resulted in unaddressed abuse and the potential for emotional distress among vulnerable residents.