Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of sexual trauma and multiple psychiatric diagnoses, including PTSD, was sexually assaulted by another resident. The assaulted resident required extensive to total assistance with most activities of daily living and had intact cognition. The incident took place in the resident's room, where the perpetrator entered and engaged in non-consensual sexual contact, including digital vaginal penetration and groping, despite the resident's verbal objections and distress. The event was discovered when a CNA entered the room and observed the perpetrator's hand near the resident's waist. Upon questioning, the resident disclosed that the perpetrator had touched her inappropriately and against her will. The resident reported pain and emotional distress, and a subsequent SANE exam confirmed internal injuries consistent with sexual assault. The resident's roommate was not present during the assault, and staff were not in the room at the time, allowing the incident to occur without immediate intervention. Following the assault, the resident experienced a significant decline in her mental health, including increased anger, depression, fear, flashbacks, nightmares, and anxiety, all of which were documented in psychiatric progress notes. The resident expressed fear of encountering the perpetrator again and reported feeling unsafe in her living environment. The incident was reported to facility management, law enforcement, and a SANE exam was conducted to document the injuries.