Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from nonconsensual sexual contact, resulting in a deficiency related to abuse prevention. According to the report, one resident with a diagnosis of Alzheimer's disease and severely impaired cognition was found in another resident's room. The second resident, also with severely impaired cognition and a documented history of inappropriate sexual behaviors, was observed naked and straddling the first resident, with his hand inside her brief. Staff discovered the incident when a registered nurse and a certified nurse aide were searching for the first resident, who was known to wander into other rooms. Prior to the incident, the care plan for the resident with a history of inappropriate sexual behaviors included interventions such as observing interactions with female residents, separating residents if necessary, and providing supervised socialization. There was also documentation of recent increased sexualized behaviors, including exposing genitalia and fondling himself in front of staff. A request for psychiatric evaluation had been made due to these behaviors, but the psychiatric visit did not occur until after the incident. The facility's policy stated that residents must not be subjected to abuse by other residents. Despite this, the interventions in place were not sufficient to prevent the incident of nonconsensual sexual contact. The failure to implement effective monitoring and timely psychiatric intervention contributed to the occurrence of abuse between the two residents, both of whom had severely impaired cognition and were vulnerable to such incidents.