Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse and harassment by another resident, despite documented evidence of prior sexually inappropriate behaviors. One resident, who was severely cognitively impaired and had a history of sexualized behaviors, including making sexual comments and gestures toward staff, was known to require two-person assistance for care and had been referred to psychiatric services. Despite these interventions, the resident continued to display inappropriate behaviors, including an incident where he attempted to inappropriately grab staff. Another resident, also severely cognitively impaired and lacking the capacity to consent to sexual contact, became the victim of sexual abuse during a scheduled activity, where the first resident was observed touching her breast and genital area. Staff intervened immediately, but the incident was not reported to the Department of Health, as facility leadership did not perceive intent on the part of the perpetrator and only increased supervision as a response. A subsequent incident occurred in the dining room, where the same resident touched the victim's buttocks, which was witnessed and documented by staff. Only after this second incident did the facility report the matter to the appropriate authorities and implement more stringent supervision and separation measures. The facility's documentation and interviews with leadership revealed a lack of sufficient safeguards to prevent recurring sexual harassment or abuse, and there was no evidence that the facility ensured the victim was free from such abuse, as required by policy and regulation.