Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Alleged Sexual Assault
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation when another resident physically and allegedly sexually assaulted her. The incident involved a female resident with a history of non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia, who was found with multiple bruises and red marks on her neck. She reported that a male resident had entered her room, attempted to touch her inappropriately, and later, in a common area, choked and sucked on her neck. The male resident, who also had non-Alzheimer's dementia and a prior history of inappropriate sexual behavior, denied any involvement and was unable to provide details due to cognitive impairment. The male resident's care plan had previously identified a risk for inappropriate sexual behaviors, including an incident months earlier where he kissed another female resident. Despite this, there was no evidence of ongoing enhanced supervision or interventions to prevent further incidents, and staff did not observe or anticipate any further behaviors from him. On the day of the incident, staff discovered the injuries after dinner when the female resident was in the TV room with the male resident and another resident. Upon questioning, the female resident identified the male resident as the perpetrator, and her account was consistent with her injuries. Staff interviews confirmed that the residents were often together in common areas and that the male resident had not previously exhibited such behaviors since the earlier incident. The deficiency was identified because the facility did not ensure all residents were free from abuse, as required. The staff had not been fully trained on resident-to-resident abuse prevention at the time of the incident, and the male resident's prior behavioral risks were not adequately addressed to prevent recurrence. The failure to implement sufficient preventive measures and staff training placed residents at risk for abuse.