Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A resident with quadriplegia, cerebral palsy, and decreased range of motion, who requires a mechanical lift and assistance from two staff members for mobility, was not protected from sexual abuse by another resident. The cognitively intact resident was unable to reposition themselves in bed and was therefore unable to move away from their roommate, who is independently mobile in a wheelchair. On multiple occasions, staff observed the roommate sitting next to the resident's bed and masturbating. The roommate was also seen rummaging through the resident's personal belongings. The affected resident reported feeling uncomfortable and scared as a result of these incidents. Facility records, including care plans and progress notes, document that staff intervened when the roommate was found engaging in inappropriate behavior but the incidents recurred. The facility's abuse prevention policy defines such actions as abuse, regardless of the mental or physical condition of those involved. Interviews with the DON and Administrator confirmed the events, and the resident's discomfort and fear were substantiated by both staff observations and the resident's own statements.