Failure to Prevent and Respond to Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a known history of sexually inappropriate behavior was not adequately supervised, resulting in unsolicited sexual contact with another resident. The incident took place in a hallway and common areas where both residents, who ambulated independently via wheelchairs, were left unmonitored by staff. Despite care plan interventions and hall sheets indicating that both residents required 1:1 supervision within arm's length at all times, staff failed to maintain the required level of monitoring. Camera footage confirmed that staff, including a CNA and an LPN, were not present or did not intervene during multiple interactions, allowing the resident to touch the other resident's private area without consent. The resident who committed the inappropriate act had a documented history of dementia, altered mental status, anxiety, and previous sexually inappropriate behaviors, necessitating close supervision in common areas. The other resident had diagnoses including dementia, anxiety, psychotic disturbance, and mood disturbance, with significant communication limitations. Despite these known risks, staff did not follow the supervision protocols outlined in the care plans and staff meeting notes, which specifically required staff to be within arm's length of the resident with a history of inappropriate behavior. Additionally, after the incident, there was a lack of immediate assessment and documentation regarding the well-being of the resident who was touched. The LPN did not complete an assessment or incident report at the time, and the Director of Nursing did not initiate an internal investigation until several days after becoming aware of the incident. The facility's abuse prohibition policy required prompt reporting, assessment, and investigation of suspected abuse, but these procedures were not followed in this case.