Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents on a secured unit. One resident with severely impaired cognition and a history of dementia, cerebral infarction, and psychotic disorder was found in her room with her pants down, while another resident, who was cognitively intact, was observed touching her in the peri-area. Staff immediately separated the residents and notified the nurse, who performed a head-to-toe assessment and found no injuries. The family and physician were notified, and the resident declined medical attention. Interviews with staff confirmed the incident, with a CNA stating she witnessed the inappropriate contact and immediately intervened. The DON acknowledged that the facility had not provided abuse education to all staff or conducted follow-up audits or monitoring related to abuse concerns. The Social Service Director stated that the resident who was touched did not have the cognitive capacity to consent to a sexual encounter, and the resident herself could not recall if she had consented to the contact. The facility's policy defines sexual abuse as non-consensual sexual contact of any type with a resident and requires investigation of all alleged violations. Despite this, the Administrator concluded that the encounter was mutual and did not substantiate the allegation of abuse after completing the investigation. The police were notified but did not investigate further. The facility's actions and lack of comprehensive staff education and monitoring contributed to the failure to ensure the resident was free from sexual abuse.