Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents with impaired cognition from potential sexual abuse by not ensuring adequate supervision and adherence to care plan interventions. One incident involved a resident with dementia and behavioral disturbances being found with another cognitively impaired resident in her room late at night, where the male resident admitted to kissing and holding hands with her. The female resident, who was not to be left alone with male residents due to her cognitive status and lack of safety awareness, was found awake with her knees elevated, and could not recall the incident when later questioned. The male resident had a documented history of wandering into female residents' rooms and displaying physical affection, with a behavior contract and specific monitoring interventions in place, including door alarms and staff supervision requirements. Despite these interventions, staff failed to consistently monitor the whereabouts of both residents and did not prevent unsupervised contact. Another incident occurred in the dining room, where the male resident was observed sitting next to the female resident and placing his hand on her knee, despite care plan instructions that he should not be within five feet of female residents without supervision. New dietary staff were unaware of these restrictions, further contributing to the failure to protect residents from potential abuse. The facility's lack of effective supervision and failure to implement care plan interventions resulted in residents not being free from potential sexual abuse.