Failure to Protect Residents from Sexual and Psychosocial Abuse
Penalty
Summary
The facility failed to protect residents from sexual and psychosocial abuse perpetrated by another resident. One resident reported being physically and sexually abused by another resident, including being hit with a wheelchair and having her crotch touched through her clothing. The resident stated she reported the incident to a nurse aide, who did not take the allegation seriously, laughed, and failed to report it. The resident also reported repeated unwanted physical contact and verbal threats from the same resident, including being slapped and having her personal space invaded. Staff and other residents confirmed that the alleged perpetrator had engaged in similar behaviors with both residents and staff, and that some staff found these actions humorous rather than concerning. Despite the resident's repeated attempts to file a complaint and requests for intervention, the facility did not treat the incident as an allegation of abuse. Instead, the incident was logged as a customer service grievance, and the staff member involved received only basic customer service education, with no mention of abuse identification or reporting. The facility's response to the resident was to instruct her to avoid the alleged perpetrator, without implementing any interventions to ensure her safety or prevent further abuse. The facility did not report the incident to the appropriate authorities or conduct a thorough investigation at the time of the allegation. Interviews with facility leadership and staff revealed a lack of understanding and appropriate response to allegations of sexual abuse. The DON and Administrator stated they would report incidents of sexual abuse to law enforcement, but in this case, they did not consider the incident reportable. The resident continued to feel unsafe and altered her behavior to avoid the alleged perpetrator, expressing distress and a lack of protection in her living environment. The failure to identify, report, and address the abuse placed all residents at risk.