Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement necessary protective measures following a resident-to-resident sexual incident involving two residents. On the date of the incident, one resident was found in another resident's room with her hand on his penis, and the second resident's brief was undone. Both residents were assessed for injury, and the incident was reported to the appropriate staff. However, the facility's investigation documents did not include evidence of staff education for abuse prevention related to the incident, nor did they show that monitoring for sexual behaviors was implemented for the initiating resident. Additionally, although staff were reportedly charting behavior monitoring for the initiating resident, there was no indication that sexual behaviors were specifically identified or targeted for ongoing monitoring. The care plan for the initiating resident referenced behavioral issues such as shouting and wandering, but did not address sexual behaviors, focus areas, goals, or interventions related to the incident. The most recent documented staff in-service training on abuse/neglect occurred three weeks prior to the incident, with no documentation of additional training provided after the event.