Failure to Prevent Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent sexual abuse involving a resident with a history of aphasia, paraplegia, anxiety, and neuromuscular dysfunction, who was cognitively intact and dependent on staff for bed mobility, transfers, and toileting. During a staff member's rounds, another resident with diagnoses including alcohol-induced persisting dementia, stroke, aphasia, schizophrenia, and Wernicke's encephalopathy, and also with intact cognition, was observed in the first resident's room engaging in inappropriate sexual contact. The incident occurred after the second resident, who resided in a locked Memory Support Unit (MSU) and was considered an elopement risk with aggressive behaviors, was allowed to re-enter the facility unsupervised during a smoke break, contrary to the expectation that MSU residents be observed at all times outside the unit. Staff interviews and documentation revealed that the inappropriate contact was witnessed by a CNA, who immediately intervened and separated the residents. The resident who was touched reported being awoken by the incident and stated he did not consent to the contact. The staff member who allowed the second resident to return inside unsupervised assumed she had gone back to the unit after the smoke break, but she instead entered the other resident's room. The facility's policy required residents to be free from abuse and neglect, and staff were expected to supervise MSU residents at all times when outside the unit. The incident was reported to the nursing leadership, and an internal investigation confirmed that the lack of supervision during the smoke break allowed the resident from the MSU to access another resident's room and commit the act of sexual abuse. The failure to maintain required supervision directly led to the opportunity for the abuse to occur, in violation of facility policy and resident rights.