Failure to Prevent Sexual Abuse in Common Area
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from sexual abuse by another resident in a supervised common area. The incident involved a cognitively intact resident with mental health diagnoses who engaged in non-consensual sexual contact with a resident diagnosed with Alzheimer's Disease, Dementia, and Anxiety Disorder. The cognitively impaired resident was unable to consent, resist, or report the incident. The event occurred in a common area where the resident was seated in a geriatric chair, and the other resident approached in a wheelchair, initiated conversation, and then proceeded to lift the blanket and touch the resident inappropriately for several minutes before staff intervention. Staff interviews and video footage confirmed that the abuse occurred over a period of approximately three minutes before a CNA intervened. The positioning of the residents, staff, and physical barriers in the area made it difficult for staff to observe the inappropriate contact until it was reported by a visitor and later confirmed by video review. Facility policy required the prevention of abuse, neglect, and exploitation, but the failure to adequately supervise and protect the resident resulted in actual harm.