Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to protect a severely cognitively impaired female resident from sexual abuse by another resident. On two separate occasions, a male resident with moderate cognitive impairment was observed engaging in sexually inappropriate contact with the female resident, who was unable to consent due to her severe cognitive impairment. In the first incident, the male resident lifted the female resident’s breasts out of her shirt and fondled them in a public area of the facility. In the second incident, the same male resident took the female resident’s hand and rubbed it over his pants in his crotch area. Both incidents were witnessed by staff, who intervened to separate the residents. The male resident had a history of dementia, cognitive communication deficit, and other medical conditions, but there was no care plan in place addressing sexually inappropriate behaviors prior to the first incident. The female resident had Alzheimer’s dementia, was severely impaired in daily decision making, and required total assistance with most activities of daily living. She was dependent on staff for mobility and transfers and was unable to provide a reliable account of the incidents due to her cognitive status. Staff interviews confirmed that the male resident had previously made inappropriate sexual comments to staff but had not been known to touch other residents inappropriately before these events. Despite the initial implementation of one-to-one supervision for the male resident following the first incident, supervision was not consistently maintained, as evidenced by observations of the resident without a sitter at the nurses’ station and in the hallway. Staff were unclear about the requirements for one-to-one supervision, and the male resident was able to approach and have further inappropriate contact with the same female resident. The lack of a care plan addressing the male resident’s behaviors and inconsistent supervision contributed to the recurrence of resident-to-resident sexual abuse.