Failure to Prevent, Report, and Investigate Sexual Abuse of a Non-Verbal Resident
Penalty
Summary
The facility failed to follow its abuse prevention policy in the case of a non-verbal, severely cognitively impaired resident who was unable to consent to sexual activity. On one occasion, a CNA observed another resident with a history of inappropriate contact attempting to get into bed with the non-verbal resident. The day prior, the same resident was observed with his hand inside the non-verbal resident's diaper in a public area. Despite these incidents, the facility did not report the initial allegation to law enforcement or the Department, nor did they implement interventions to prevent further abuse. Staff interviews revealed that after the first incident, the involved resident was not placed under enhanced supervision and continued to have access to the non-verbal resident. The care plan for the non-verbal resident did not address risk of abuse or neglect, and the facility's response to the initial report was limited to internal review of surveillance footage, which did not fully capture the incident. The administrator acknowledged being notified but did not take further action, stating that it did not cross her mind to report the allegation since she believed nothing had happened. Subsequently, the resident with a history of inappropriate behavior entered the non-verbal resident's room, removed her incontinence brief, and applied shaving cream to her, admitting to staff that he wanted to have sex. The incident was only reported to law enforcement after an anonymous call. The facility's own abuse prevention policy requires immediate reporting and investigation of abuse allegations, but these procedures were not followed, resulting in repeated abuse of a vulnerable resident.