Failure to Maintain Resident Dignity and Safety After Reported Sexual Incident
Penalty
Summary
The facility failed to ensure that three cognitively intact residents were treated with dignity and maintained a sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a non-interviewable resident. The facility's policy requires that residents be cared for in a manner that promotes their well-being, self-worth, and respect for their private space, but this was not upheld. Multiple residents reported that a resident with a history of wandering and inappropriate behavior entered another resident's room, closed the door, and was found in a potentially sexually inappropriate situation. Staff were observed yelling at the resident to leave the room and calling for assistance, but there was no evidence that law enforcement or the responsible representative was notified, and the affected resident was not sent for evaluation. Residents who witnessed or reported the incident described feeling unsafe and expressed concerns about retaliation from staff. One resident reported being told by staff not to "spread false rumors" and to "shut my mouth," leading to fear about future care. Another resident, who was the roommate of the resident involved in the incident, stated that he avoided his room due to discomfort and observed staff being retaliative. This resident also described the resident in question bragging about the incident to others, with staff present but not intervening appropriately. A third resident reported that the same resident had previously attempted to enter her room and had entered the room of the vulnerable resident on multiple occasions, including at night. She stated that her reports to nursing staff were dismissed and that she did not feel safe, as the resident remained on the same hall and close to the affected resident. The lack of appropriate response to these reports and the ongoing proximity of the resident in question contributed to a continued sense of insecurity and lack of dignity among the residents involved.