Failure to Protect Residents from Sexual and Mental Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse and mental abuse, as evidenced by multiple incidents involving a resident with a known history of sexually inappropriate and aggressive behavior. This resident, who was moderately cognitively impaired and had a traumatic brain injury, was on 15-minute checks for inappropriate behavior and had a care plan addressing sexual inappropriateness. Despite these measures, the resident inappropriately touched another resident, who was also moderately cognitively impaired and at risk of abuse due to impaired cognition. The affected resident reported being touched in the genital area by the known perpetrator while at the nurse's station, resulting in emotional distress, crying, and being visibly shaken. Staff interviews confirmed the incident and acknowledged the perpetrator's history of similar behaviors toward both staff and residents. Another incident involved a cognitively intact resident who reported that the same perpetrator offered money for a sexual act and grabbed her sweater at the nurse's station. Although this incident did not involve physical touching of private areas, the resident reported the event to staff, but no abuse investigation was conducted. The administrator expressed uncertainty about whether the incident constituted sexual abuse, citing the lack of physical contact. The facility's abuse prevention policy defines abuse to include both unwanted intimate touching and verbal or nonverbal conduct causing humiliation, intimidation, or fear. The failure to recognize and investigate these incidents, despite clear policy definitions and resident reports, contributed to the deficiency.