Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A female resident with a significant history of PTSD, sexual assault, and other mental health conditions was subjected to inappropriate sexual touching by a male resident with dementia and moderate cognitive impairment. The male resident was known to have a potential for aggressive or threatening behavior, and his care plan included interventions to respect his personal space. The female resident's care plan specified only female caregivers due to her trauma history. On the day of the incident, the male resident grabbed the female resident in the crotch and later in the buttocks as she walked past him in a common area. Multiple staff members witnessed these incidents, and it was noted that the male resident had previously attempted to touch the female resident, though not as successfully or in such a targeted manner. Staff responses to the incidents were inconsistent and delayed. Although staff separated the residents after the first incident, the male resident was able to touch the female resident a second time. Witness statements indicated that staff were aware of previous attempts by the male resident to touch the female resident, and some staff considered these behaviors to be harmless. There was confusion among staff regarding the timing and number of incidents, and discrepancies were found in the facility's investigation and documentation. Not all staff who may have had knowledge of the incident were interviewed, and there was a lack of clarity about the interventions implemented immediately following the events. The facility failed to protect the female resident from further inappropriate contact after the initial incident, despite her vulnerability due to her trauma history. The male resident was not moved to a different unit until two days after the incident, and there was a delay in obtaining a psychiatric evaluation for him. The investigation revealed that the facility did not thoroughly assess or monitor the female resident for psychological or emotional harm following the incidents, and interventions to ensure her safety were not promptly or adequately implemented. The failure to keep the resident free from sexual abuse resulted in a finding of immediate jeopardy.