Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with a history of behavioral issues, including verbal aggression and manipulative behavior, was admitted to the facility with intact cognition and significant physical care needs. The resident's care plan documented these behaviors, and a behavioral contract was signed after allegations of inappropriate conversations and other disruptive actions. However, there was no documentation in the resident's records of inappropriate sexual conversations, and key staff members, including the DON and MDS coordinator, were unaware of the behavioral contract or any incidents of sexual inappropriateness. The resident was also noted to have left the facility against medical advice on multiple occasions and exhibited signs of possible substance use, but no illicit drugs were found during a room search. Another resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, was found in their room with the first resident. Staff discovered the first resident in the bed with the second resident, with their pants partially down, and appearing to be engaged in sexual activity. The cognitively impaired resident was nonverbal and unable to consent. The incident was reported to the DON, and the residents were separated. The first resident left the facility but was later taken into custody by police. The second resident was sent to the emergency room for evaluation, where a diagnosis of sexual assault was made, and a SANE exam was completed. The facility's documentation revealed that staff were present on the hall shortly before the incident but did not prevent the first resident from entering the second resident's room and closing the door. There was no documentation provided to surveyors regarding the implementation or monitoring of 1:1 supervision for either resident following the incident. Family members of the assaulted resident reported a lack of communication and detail from the facility regarding the incident, and staff interviews indicated a lack of awareness and documentation related to the behavioral contract and prior inappropriate behaviors.