Failure to Protect Female Residents During Sexual Abuse Investigation
Penalty
Summary
The facility failed to ensure the safety and protection of six confidential female residents during the investigation of a sexual abuse incident. An unknown male resident, with diagnoses including Diabetes Mellitus, Bipolar Disorder, and Vascular Dementia and an intact BIMS score, was observed engaging in sexual activity with a female resident in a hallway. After staff intervened, the male resident was initially returned to his room and later moved to another room on the same floor, but still in proximity to the alleged victim and other female residents. The facility did not implement additional protective measures beyond relocating the resident, despite the potential for further contact with vulnerable residents. Observations revealed that the hallway where the male resident was moved was directly accessible to several other rooms occupied by female residents, and there were periods when no staff were present on the floor or at the nurse's station. Interviews with facility leadership confirmed that no further precautions were taken to protect the other residents during the period between the incident and the male resident's discharge. The facility's abuse policy required protection of residents during investigations, including increased supervision or immediate transfer if indicated, but these measures were not fully implemented.