Failure to Protect Resident from Sexual Abuse Due to Inadequate Response to Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in one resident being subjected to indecent exposure by another resident. Specifically, a resident with severe dementia, psychosis, and a history of bizarre and hypersexual behavior, including public masturbation and exposing himself in hallways, was placed in a shared room. Despite staff being aware of this resident's ongoing inappropriate sexual behavior, including an incident where he masturbated in the presence of his roommate, the facility did not take adequate measures to prevent further exposure or ensure the safety of the roommate. The affected roommate, who had a history of acute subdural hemorrhage and mobility difficulties but was cognitively intact, reported feeling unsafe and unable to sleep due to fear of what might happen. The roommate communicated his discomfort and concerns to nursing staff, who only advised him to use the call light if something happened, rather than taking immediate protective action or removing him from the situation. Staff interviews confirmed that the inappropriate behavior was known and had been reported to the previous DON, but the behavior was attributed to the resident's dementia and not recognized as sexual abuse. Facility policy required prompt reporting and thorough investigation of all abuse allegations, but the incident was not reported to the administrator as required. Staff interviews indicated a lack of clarity regarding which residents were exposed and whether the situation was safe, with one RN supervisor acknowledging that it was not safe for the roommate to be alone with the resident exhibiting inappropriate sexual behavior. The facility's failure to act on known risks and to follow abuse reporting protocols resulted in a resident being subjected to sexual abuse and feeling unsafe in his living environment.