Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of sexually inappropriate behaviors, including explicit comments and inappropriate touching due to dementia, engaged in unwanted sexual contact with another resident. The incident took place as both residents were self-mobilizing in their wheelchairs after breakfast, when the resident with dementia reached out and cupped the other resident's breast and blew kisses at her. The care plan for the resident with dementia included instructions for staff to be observant of his interactions with others, intervene as necessary to protect the rights and safety of others, and remove him from situations as needed. Despite these care plan interventions, the incident occurred, indicating a failure to ensure adequate supervision and protection for residents from abuse. The resident who experienced the unwanted contact had intact cognition but expressive aphasia, and was able to confirm the inappropriate touching during a social worker interview. She did not express fear or a lack of safety following the incident. The facility's policy clearly stated that every resident has the right to be free from abuse, but this right was not upheld in this instance.