Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a female resident with severe cognitive impairment from abuse by another male resident with a known history of wandering and inappropriate behaviors. The male resident, who was cognitively intact but exhibited behaviors such as wandering, rummaging, and public sexual acts, entered the female resident's room without staff awareness and remained there with the door closed for approximately eight minutes. During this time, staff were not present in the hallway, and the male resident was later found standing at the head of the female resident's bed with his pants lowered and genitals exposed near her face. The female resident was asleep, unable to verbalize her needs, and fully dependent on staff for activities of daily living. Staff interviews and record reviews revealed that the male resident was known among staff for entering other residents' rooms and taking their belongings, and that staff had expressed concerns about his behavior prior to the incident. Despite these known risks, there was no individualized care plan addressing his inappropriate wandering or sexually inappropriate behaviors, aside from standard two-hour monitoring. Staff also reported that they were responsible for supervising a high number of residents, making it difficult to provide adequate supervision, and that the male resident would take advantage of moments when staff were not watching. Following the incident, it was discovered that the facility did not promptly notify the female resident's family, hospice care team, or primary physician about the alleged abuse. This delay in notification meant that appropriate medical assessments and interventions, such as evaluation for trauma or sexually transmitted infections, were not conducted in a timely manner. The facility's failure to supervise the male resident and protect the vulnerable female resident from harm constituted a significant breakdown in resident safety and resulted in an Immediate Jeopardy to health and safety.