Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual abuse by another resident who exhibited a pattern of inappropriate sexual behaviors. One resident with significant cognitive impairment and a history of hypersexuality was repeatedly observed or reported to have engaged in non-consensual sexual contact with several other residents, all of whom had documented cognitive deficits or dementia and lacked the capacity to consent to sexual activity. Incidents included the resident putting hands down another resident's pants and touching the perineal area, rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. These events occurred in various locations within the facility, including resident rooms and common areas, and were witnessed or reported by staff on multiple occasions. Despite these repeated incidents, there was no evidence that the facility implemented new or effective interventions to protect the affected residents or prevent further abuse after each event. Documentation showed that staff often redirected the resident or removed them from the situation, but there was no indication of comprehensive assessment, increased supervision, or other protective measures being put in place following the incidents. Additionally, the facility did not consistently notify the families or representatives of the affected residents about the incidents, nor did they document assessments of the residents' capacity to consent to sexual contact, as required by facility policy. Interviews with staff and administration revealed a lack of awareness and communication regarding the ongoing behaviors and incidents. Key leadership, including the DON and Administrator, were not informed of several incidents until much later, and some staff did not recognize the behaviors as abuse, attributing them instead to memory care behaviors. The facility's policies required assessment of capacity to consent and interventions to prevent abuse, but these were not followed. The affected residents all had diagnoses of dementia or other cognitive impairments, and their representatives confirmed that the residents would not have wanted or been able to consent to such contact.