Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, dependent on staff for most activities of daily living and under a public legal guardian, was subjected to non-consensual sexual contact by another resident. The resident's medical record indicated a BIMS score of six, signifying severely impaired cognition and inability to communicate effectively. Multiple incidents were documented in which the alleged perpetrator, who had moderately impaired cognition, was observed engaging in inappropriate physical contact with the victim, including fondling the resident's breast and placing a hand between the resident's legs. On separate occasions, staff observed the perpetrator with their hand under the victim's shirt and between the victim's legs. Witness statements and progress notes described the victim as visibly shaken and trembling during and after the incidents. Despite previous observations and interventions, such as moving the perpetrator to a different area and educating them about resident privacy, the inappropriate contact recurred. Staff and administration were notified after each incident, and documentation shows that the events were reported to the DON, Administrator, physician, and the victim's guardian. The facility's failure to prevent repeated sexual abuse incidents between these two residents, despite prior knowledge of inappropriate behavior and the victim's vulnerability, resulted in the resident being subjected to non-consensual sexual contact. The facility's policies prohibit such abuse, but the documented events demonstrate that the resident was not adequately protected from sexual abuse by another resident.