Failure to Protect Residents from Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, resulting in two separate incidents involving inappropriate sexual contact and comments. In the first incident, a cognitively intact male resident made sexually explicit statements and touched a female resident's breasts without her consent on multiple occasions, both in the courtyard and near a nurse's station. The female resident reported that she had told the male resident to stop and had not consented to any such contact or conversation. Despite the male resident's care plan noting behavioral issues, it did not specify the nature of these behaviors or include targeted interventions to address the risk of inappropriate sexual conduct. The female resident's care plan also lacked any focus on behaviors or risk of abuse, despite her reports of ongoing unwanted attention and sexual comments from the male resident. In the second incident, a moderately cognitively impaired male resident was observed by a nurse aide with his hand on the genital area of a severely cognitively impaired, non-verbal female resident in the dining room. Both residents were fully clothed, and the female resident did not display any reaction or distress due to her advanced dementia. The male resident denied any inappropriate intent, claiming he was shooing a fly, and had no prior documented history of inappropriate behaviors toward other residents. The care plans for both residents did not address the risk of inappropriate behaviors or include interventions to prevent such incidents. In both cases, the facility's documentation and care planning failed to identify or mitigate the risk of resident-to-resident sexual abuse. There was a lack of specific behavioral interventions or monitoring for residents with known or potential behavioral issues. The facility did not provide evidence of a corrective action plan regarding its failure to protect residents' rights to be free from abuse, and the care plans did not reflect the residents' behavioral risks or needs for supervision in communal areas.