Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to monitor and prevent resident-to-resident sexual abuse involving two residents, both of whom had severe cognitive impairment as indicated by their BIMS scores of 3 out of 15 and diagnoses of dementia and Alzheimer's Disease. On the date of the incident, one resident was observed groping another resident's breast while both were seated in a common area. Staff witnessed the incident, with the victim attempting to defend herself by repeatedly slapping the perpetrator's shoulder. The victim later reported feeling violated and upset, and her family member confirmed her distress following the event. Documentation and interviews revealed that the perpetrating resident had a documented history of physical and sexually abusive behaviors toward others, occurring every 4 to 6 days. Staff statements and facility records confirmed the sequence of events, including the immediate reactions of both residents and the staff's awareness of the incident. The facility's policy on abuse prevention was reviewed, which states residents' rights to be free from all forms of abuse, including sexual abuse. The Nursing Home Administrator acknowledged that sexual abuse had occurred during the incident.