Failure to Prevent and Assess Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and a comprehensive assessment to prevent resident-to-resident sexual abuse. A resident with a history of PTSD and cognitive impairment reported receiving unwanted, sexually explicit notes and advances from another resident over a period of months. Multiple residents expressed feeling unsafe due to the behaviors of the resident delivering the notes, and several staff members, including the DON and social worker, were made aware of the situation through direct reports, grievances, and resident council meetings. Despite these reports, the facility did not complete a comprehensive assessment of the affected resident for psychosocial harm, nor did it implement effective interventions or monitoring systems to ensure her safety and well-being. The affected resident had a documented history of childhood sexual abuse, PTSD, anxiety, depression, and cognitive impairment. Her care plan identified a need for a safe environment and support for coping with trauma, but interventions were limited to general reassurances and reminders, without specific measures to address the ongoing harassment. The resident repeatedly reported feeling unsafe, experiencing increased PTSD symptoms, and having trouble sleeping due to the unwanted attention and fear of further abuse. Other residents and staff corroborated the ongoing nature of the harassment, including the delivery of sexually explicit notes and unwanted advances in unsupervised areas such as the smoking area. The facility's response to the reports was inadequate, as staff primarily addressed the issue by speaking to the resident delivering the notes and advising the affected resident to avoid him. There was no evidence of a thorough assessment of the affected resident's psychosocial harm, no clear documentation of interventions to ensure her safety, and no updates to the care plan of the resident exhibiting the inappropriate behaviors. The facility also failed to monitor or restrict interactions effectively, and did not promptly report the abuse to the State Agency as required. The lack of comprehensive assessment, supervision, and timely intervention resulted in ongoing psychosocial harm to the affected resident and a failure to protect her and others from further abuse.