Failure to Prevent and Monitor Sexual Abuse Among Residents
Penalty
Summary
The facility failed to adequately monitor and prevent sexual abuse involving a resident with severe cognitive impairment and behavioral disturbances. The resident, diagnosed with unspecified dementia and severe cognitive impairment, was repeatedly found in situations with another resident where inappropriate sexual behaviors were observed or alleged. Documentation shows that the resident was found in another resident's room, with both individuals on the bed and one resident's pants unzipped. There were also multiple reports of the resident making sexually suggestive gestures and engaging in inappropriate physical contact, such as holding hands and touching another resident's upper body. Staff and nursing notes indicate that these incidents were recurrent, with the resident being redirected or separated from others on several occasions. Despite these interventions, the inappropriate behaviors continued, and there were lapses in the implementation and documentation of one-on-one supervision. The facility's policy required thorough investigation and prevention of abuse, but the records show inconsistent monitoring and supervision, with periods where one-on-one documentation was missing for several days, even after the DON had indicated that such supervision was necessary until the behavior was resolved. Interviews with staff confirmed that the resident's behaviors were known and that supervision was inconsistently applied, with activity staff and nurses rotating responsibility for monitoring. The DON determined when to start and stop one-on-one supervision, but there was no clear or consistent protocol followed, and the resident continued to interact primarily with cognitively impaired residents. The failure to maintain consistent supervision and prevent further incidents resulted in the facility not protecting residents from sexual abuse as required by policy.