Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, both of whom were severely cognitively impaired and lacked the ability to consent. The incident involved one resident in a wheelchair placing their hand under another resident's shirt and rubbing their breast, as witnessed by another resident and a certified nurse aide. Both residents involved had significant cognitive impairments, with one diagnosed with dementia, depression, and diabetes, and the other with aphasia, Alzheimer's disease, and PTSD. Care plans for both residents identified them as being at risk of victimization due to their cognitive limitations and inability to understand their surroundings. Despite documented interventions to provide support and ensure a safe environment, the incident occurred in a common area after an activity, where one resident repeatedly approached the other. Staff had to intervene multiple times, but the inappropriate contact still took place and was reported by witnesses. The facility's policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the investigation found reasonable cause to believe that abuse had occurred.