Failure to Protect Resident from Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency was identified when the facility failed to protect a resident from abuse, specifically resident-to-resident sexual abuse. The incident involved a cognitively intact resident with a history of anoxic brain damage, major depressive disorder, and anxiety disorder, who reported being pushed down on a bed, held down, and subjected to unwanted kissing by another resident. The resident stated they told the perpetrator to stop and eventually left the room after a few minutes. The incident was not immediately reported to the appropriate authorities, and the resident indicated that after the event, the perpetrator continued to approach them in common areas, causing the resident to feel afraid and to isolate themselves in their room for approximately two weeks. The facility's policy required thorough investigation and documentation of all alleged or actual incidents of abuse, including obtaining detailed accounts from the resident and assessing for mood or behavioral changes. However, the report shows that the initial allegation was not promptly or thoroughly investigated. The resident stated they had reported the incident to staff, but staff interviewed by police denied knowledge of the abuse. Documentation indicates that the administrator was eventually informed, and a care plan was developed identifying the resident as at risk for unwanted physical contact, but this occurred after a significant delay from the time of the incident. Records also show that the facility did not immediately notify the appropriate authorities or conduct a timely assessment of the resident's well-being following the allegation. The resident's statements and subsequent interviews revealed that the incident had a negative impact on their sense of safety and emotional state. The facility's failure to promptly investigate, document, and protect the resident from further unwanted contact constituted a deficiency in ensuring residents are free from abuse.