Failure to Supervise and Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision and protection for a severely cognitively impaired, non-verbal resident with a history of psychosis and dependence for mobility. The resident's care plan did not address the risk of abuse or neglect, despite her vulnerability. Another resident, who was cognitively intact but had a documented history of inappropriate contact with peers and staff, was not placed on enhanced supervision or restricted from moving freely about the facility after an initial incident of inappropriate contact was observed. On one occasion, a CNA observed the resident with a history of inappropriate behavior with his hand inside the vulnerable resident's diaper, claiming to be checking it. This incident was reported to the LPN and the facility administrator, but no immediate action was taken to increase supervision or separate the residents. The following day, the same resident was found in the vulnerable resident's room, attempting to get into bed with her, with his pants down and shaving cream on his hands. Staff found shaving cream on the vulnerable resident's buttock, and the resident admitted to wanting to have sex with her. The vulnerable resident was non-verbal and unable to consent to sexual activity. Despite staff and psychiatric documentation of the incidents and the resident's admission of intent, the facility did not implement interventions to prevent further contact or abuse after the initial event. The facility's abuse prevention policy states a zero-tolerance approach and the need to protect residents from abuse, but this was not followed, resulting in repeated incidents of sexual abuse and lack of adequate supervision for both residents involved.