Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. An incident occurred in which one resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found in bed while another resident, also with severe cognitive impairment and a diagnosis of dementia, was observed with their hand underneath the first resident's gown, making a fondling motion. The resident being touched was unable to respond appropriately to the situation or to questions, and the staff member who discovered the incident reported that the resident being touched was unaware of their circumstances or surroundings. Prior to the incident, there were no documented behavioral issues or similar incidents involving the resident who committed the inappropriate touching. Staff interviews indicated that this resident had previously entered another resident's room to use the bathroom but had not exhibited sexually inappropriate behavior before. The staff member who discovered the incident was alerted by a housekeeper and intervened immediately. The resident who was touched had a history of metabolic encephalopathy, severe memory and thinking problems, and was dependent on staff for all personal care needs. The facility's policy prohibits and aims to prevent all forms of abuse, including sexual abuse, and requires the protection of residents' health, welfare, and rights. Despite these policies, the incident occurred, and the resident was subjected to unwanted sexual contact. The event was witnessed and stopped by staff, but the deficiency lies in the facility's failure to prevent the occurrence of this inappropriate and non-consensual contact between residents.