Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a female resident with multiple cognitive and psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, dementia, and moderately impaired cognition, from sexual abuse. The incident occurred when a certified nursing assistant (CNA) discovered the female resident in a male resident's bed, with no clothing from the waist down, while the male resident was standing nearby with his belt buckle undone. Both residents had documented moderate cognitive impairment, and the female resident was only oriented to person, not to place or time. Upon discovering the situation, the CNA attempted to separate the residents but was threatened by the male resident, who became aggressive and told the CNA to leave. The CNA left the room without separating the residents or ensuring the female resident's safety, and went to report the incident to the charge nurse in another unit. During this time, no staff remained in the room to supervise or protect the residents. When the licensed vocational nurse (LVN) arrived a few minutes later, the female resident was still exposed and the male resident was present, with no staff having intervened in the interim. Interviews with facility staff, including the CNA, LVN, director of staff development, assistant director of nursing, and director of nursing, confirmed that the CNA should not have left the two residents alone together and that the situation could have been prevented if the residents had been separated or supervised. The facility's abuse prevention policy states that residents have the right to be free from abuse, but this policy was not followed in this instance, resulting in the female resident's exposure and lack of protection from potential sexual abuse.