Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A cognitively impaired male resident with a history of frontal lobe and executive function deficit, impulse disorder, and dementia with behavioral disturbances was documented to have repeatedly entered the rooms of female residents without consent. Despite prior documentation of his inappropriate and unsafe behaviors, including wandering, entering female residents' rooms, and being redirected multiple times, the facility did not implement timely or adequate interventions to prevent further incidents. On one occasion, the resident was found in the room of a non-interviewable, vegetative female resident, with staff and other residents reporting that he touched her inappropriately. Multiple staff and residents reported previous similar incidents, and concerns were raised about the lack of effective action to prevent recurrence. The female resident involved was in a vegetative state, fully dependent on staff for all activities of daily living, and unable to protect herself or report abuse. There was no documentation in her medical record related to the incident, and a required head-to-toe skin check assessment was left incomplete. The resident's representative was not informed of the incident by facility staff and only learned of it from another resident. Staff interviews revealed that some were instructed by administration to alter documentation to downplay the incident, and law enforcement was not notified. The male resident was sent to the hospital for evaluation but returned the same day and was placed back in proximity to the female resident. Multiple interviews with staff and residents confirmed that the male resident's behaviors were known and had been reported prior to the incident, but interventions such as room changes or increased supervision were not implemented in a timely manner. Staff expressed concerns that the facility did not take appropriate steps to protect vulnerable residents, failed to notify responsible parties, and did not follow abuse reporting protocols. The facility's inaction and lack of adequate interventions resulted in a failure to protect the female resident from a non-consensual sexual encounter.