Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in two separate incidents involving non-consensual sexual contact. In the first incident, a resident with a history of bipolar disorder, anxiety, and major depressive disorder, who was cognitively intact, reported that another resident with moderately impaired cognition grabbed their breast without consent while they were outside in the courtyard. The victim expressed fear of being alone and of further encounters with the perpetrator. The incident was witnessed by another resident, and the victim was visibly distressed when recounting the event. Approximately four hours after the first incident was reported, staff discovered another resident, who had dementia and impaired cognition, in the perpetrator's room. This resident was found sitting on the bed with their shirt pulled up, exposing their breasts, and their pants were on inside out. The resident was distraught and tearful, refused to return to their room, and instead stayed in the common area overnight. Staff interviews and documentation confirmed that this resident required moderate to maximal assistance with activities of daily living and had no prior behaviors of wandering or entering other residents' rooms. The facility's records and staff interviews revealed that the perpetrator had previously made inappropriate sexual comments and advances toward other residents, including discussing sexually explicit material and making repeated requests for relationships despite being told no. The care plans for the involved residents did not address these behaviors or provide adequate interventions to prevent such incidents. Staff were not monitoring the perpetrator closely enough after the initial report of abuse, and there was a lack of supervision for the cognitively impaired resident who was later found in the perpetrator's room. These failures led to both residents being subjected to non-consensual sexual contact.