Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, by not preventing a male resident with a known history of inappropriate sexual behaviors from inappropriately touching two female residents on multiple occasions. The male resident, who had severe cognitive impairment and a history of making sexual comments and advances, was able to access and touch the breasts of two female residents, both of whom also had cognitive impairments. These incidents occurred despite the facility being aware of the male resident's behavioral history and having documented previous similar behaviors. The first female resident had severe cognitive impairment, aphasia, non-Alzheimer's dementia, and a traumatic brain injury. She required assistance with mobility and decision-making. On two separate occasions, the male resident was observed touching her chest, once under her shirt and once over her shirt, in common areas of the facility. In both cases, staff intervened after the inappropriate contact had already occurred. The second female resident, who had moderate cognitive impairment and a history of trauma, was also touched on the breast by the same male resident while being escorted to lunch. The male resident refused to stop when asked by staff and continued the inappropriate contact until physically separated. Despite the male resident's care plan including interventions such as 15-minute checks, increased monitoring, and environmental modifications (e.g., doorbells, closed doors), these measures were not effective in preventing repeated incidents of abuse. Staff interviews revealed inconsistent awareness and implementation of monitoring interventions, and there were lapses in supervision that allowed the male resident to access vulnerable residents. The facility's failure to ensure adequate supervision and effective implementation of interventions resulted in multiple instances of resident-to-resident sexual abuse.