Failure to Protect Residents from Sexual Abuse by a Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors. This resident, diagnosed with vascular dementia, depression, and anxiety, was observed and reported to have inappropriately touched female residents on multiple occasions. Documentation shows that the resident was found with his hand inside a female resident's shirt, physically moving his hand around her breast, and was later reported to have touched another female resident's chest during a smoke break. Despite these incidents, there was a lack of clear documentation and follow-up regarding the behaviors that led to increased monitoring, and staff were often unaware of the reasons for the interventions being implemented. Interviews with staff and residents revealed that the incidents were witnessed by other residents, who reported the behaviors to nursing staff. One female resident expressed anxiety and fear following the incidents, stating she was uncomfortable and worried about her safety at night. Another female resident described similar inappropriate contact and indicated that such behaviors had occurred repeatedly, particularly during transitions from the smoking area. Despite these reports, there was no evidence that management conducted thorough interviews or investigations with all involved parties, including witnesses and victims. The facility's documentation and response to the allegations were inconsistent. Staff members, including nurses and CNAs, were often unaware of the specific reasons for increased supervision or 15-minute checks. The Director of Nursing and Administrator acknowledged receiving reports of inappropriate behavior but did not ensure comprehensive documentation or investigation. The facility's policy on abuse prevention required identification, correction, and intervention in situations where abuse was likely, as well as protection of residents, but these measures were not fully implemented in response to the incidents described.