Failure to Prevent and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and take appropriate action to prevent further abuse involving a resident with a documented history of inappropriate sexual behaviors. Medical record review showed that the resident had a care plan in place due to repeated attempts to touch female staff and residents, as well as entering female residents' rooms without permission. Despite these known behaviors, the interventions outlined in the care plan, such as monitoring and redirection, were not effectively implemented, as evidenced by continued incidents of inappropriate touching and unsupervised entry into other residents' rooms. On a specific occasion, the resident was witnessed inappropriately touching another resident, which led to the implementation of 1:1 supervision and a room change. Interviews with staff confirmed that prior to this incident, the resident had been able to access other residents' rooms and engage in inappropriate behaviors without adequate supervision. Social worker progress notes over an extended period also documented ongoing behavioral issues, indicating a pattern of insufficient preventive measures and lack of thorough investigation into the resident's actions.