Failure to Protect Resident from Sexual Abuse Due to Inadequate Assessment and Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known history of masturbatory and sexually inappropriate behaviors was not adequately assessed, monitored, or care planned to address the risk these behaviors posed to other residents. Despite documentation in the care plan that the resident exhibited masturbatory behavior, there were no interventions or monitoring in place to evaluate or manage the impact of these behaviors on others. Staff, including CNAs and nurses, observed and were aware of the resident's inappropriate sexual behaviors, but these observations were not consistently documented or reported to supervisory staff or the physician. This lack of assessment and intervention led to an incident where the resident with sexually inappropriate behaviors was found on top of another resident, with exposed breasts, rubbing against the other resident and sucking the resident's chin, resulting in a visible red mark. The resident who was victimized was documented as having moderate cognitive impairment, lacking capacity to make decisions, and requiring substantial assistance with activities of daily living. Staff interviews confirmed that the victimized resident was unable to provide consent for any sexual activity, and the incident was recognized by staff as sexual abuse. Following the incident, there was no evidence that a head-to-toe assessment or vital signs were taken for either resident, nor was there documentation of monitoring the victimized resident's condition for 72 hours as required by facility policy. The facility's abuse prevention policy required assessment and monitoring of residents after such incidents, but these steps were not followed. The Director of Nursing acknowledged the failure to provide safety for the victimized resident and the lack of documentation, monitoring, and reporting of the perpetrator's sexually inappropriate behaviors.