Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents with severe cognitive impairment from resident-to-resident sexual abuse. On the date of the incident, a CNA discovered one resident in his wheelchair with his pants down while another resident was performing oral sex on him. Both residents had a history of dementia and behavioral issues, with one identified as a registered sex offender and the other exhibiting increased sexual behaviors. Staffing was notably low at the time, with only one nurse and two aides present for 42 residents due to several staff call-offs. The CNA who discovered the incident reported separating the residents immediately. Medical records and care plans for both residents indicated severe cognitive impairment and outlined interventions such as medication management, redirection, and supervision. Despite these measures, the incident occurred, and interviews with staff confirmed the sexual act between the two cognitively impaired residents. The facility's policy prohibits abuse, neglect, and exploitation, but the event demonstrated a failure to ensure residents were free from sexual abuse by others in the facility.