Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from sexual abuse by another resident. The incident involved two cognitively intact residents, one with diabetes and a below-the-knee amputation, and the other with a cognitive communication deficit. During a group activity, one resident made a joke about touching all the doughnuts, after which the other resident took a doughnut, wiped it in their crotch area, ate it, and made a comment implying they had now touched all the doughnuts. Multiple staff and witnesses confirmed the incident, with one staff member observing the affected resident become visibly upset and quiet immediately afterward. Following the incident, the affected resident reported feeling triggered by the presence of the other resident for at least a week and actively avoided them. Staff interviews indicated that the resident was angry and not acting like themselves for about a week after the event. The incident was corroborated by several staff members, including the activities director and CNAs, who noted the resident's emotional distress and confirmed that an unwanted sexual incident had occurred.