Failure to Prevent Recurrence of Nonconsensual Sexual Contact Between Residents
Penalty
Summary
The facility failed to prevent the recurrence of nonconsensual sexual contact between two residents with severe cognitive impairment. After an initial incident in which one resident kissed another and attempted to climb into the other's bed, the facility did not conduct an Interdisciplinary Team (IDT) meeting or create a care plan with interventions to address the incident. Both residents' records lacked documentation of consent for a relationship, and their care plans were not updated to include interventions to prevent further incidents or monitor their interactions and locations. Subsequently, a second incident occurred in which a staff member observed one resident placing his hand on the other's upper thigh in a common area, again without staff supervision. The staff member did not immediately intervene, instead leaving the area to notify another staff member, which allowed the inappropriate contact to continue. Interviews with staff and review of records confirmed that neither resident had the capacity to consent to sexual activity, and that the facility's policies regarding abuse prevention and response were not followed after the initial incident. Family members of both residents were notified of the incidents and expressed that they did not consent to their relatives having sexual contact with other residents and did not want them unsupervised together. The facility's Director of Nursing and other staff acknowledged that required assessments, care plan updates, and staff training were not completed following the first incident, and that these failures contributed to the recurrence of nonconsensual sexual contact between the residents.