Failure to Report and Supervise Sexual Abuse Incidents
Penalty
Summary
The facility failed to ensure residents' right to be free from sexual abuse, specifically in the case involving one resident with a history of dementia, psychosis, and hypersexual behavior. This resident was observed exposing himself and masturbating in the presence of another resident, despite prior knowledge by staff of similar inappropriate behavior occurring in the hallways. Staff interviews and record reviews revealed that the behavior was ongoing, with nursing staff noting repeated incidents and acknowledging that the resident would only stop the behavior when prompted. The staff associated the behavior with the resident's dementia but did not recognize or report it as sexual abuse at the time. The incident involved another resident who required significant assistance with daily activities and had the capacity to understand and make medical decisions. The facility's policy required prompt reporting and investigation of abuse, but the RN Supervisor only reported the behavior to the previous DON and not to the administrator or external authorities. The staff later acknowledged that the behavior constituted sexual abuse and should have been reported according to policy, but this was not done at the time of the incidents.