Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. A cognitively impaired female resident, diagnosed with Alzheimer's disease and severe cognitive impairment, was observed wandering into a male resident's room on multiple occasions. The male resident, who had a documented history of inappropriate sexual behaviors and a diagnosis of sexual disorder and dementia, was found on two separate occasions in physical contact with the female resident. On the first occasion, the male resident was observed rubbing the female resident's buttocks over her clothing. On the second occasion, the female resident was found lying on the male resident's bed with her pants and brief pulled down, and the male resident's hand was inside her genital area. Both residents were separated and redirected by staff, but no immediate interventions were implemented to prevent recurrence between the two incidents. Staff failed to notify the physician and the female resident's representative immediately after the incidents. The nurse on duty did not complete head-to-toe assessments of either resident following the events, nor were other notifications made in a timely manner. The staff member who witnessed the incidents did not report the inappropriate sexual touching to anyone immediately, instead making a note to chart the behavior and pass it on in shift report. There was a delay in implementing increased supervision and moving the female resident to a different room, as these actions were not taken until several hours after the second incident. Additionally, the facility's abuse investigation and reporting procedures were not followed as required by policy, including immediate assessment, notification, and protection of the residents involved. The male resident had a well-documented pattern of sexually inappropriate behaviors toward female staff prior to the incident, including touching, making sexual comments, and requesting inappropriate actions. Despite these known risks, interventions in place were limited to redirection and assigning male caregivers when available. The female resident was known to wander and had interventions such as stop signs on doors, but these were only somewhat effective. The lack of immediate and effective interventions, failure to follow abuse reporting protocols, and insufficient supervision directly led to the recurrence of resident-to-resident sexual abuse and the resulting severe psychosocial harm to the female resident.
Removal Plan
- Completed abuse training for all staff
- Increased monitoring and surveillance for Resident B and Resident C
- Updated care plans
- Resident C was sent to be evaluated at a psychiatric facility
- Completed physical assessments of residents on the secured dementia care unit
- Developed quality assurance actions for ongoing monitoring