Failure to Prevent Sexual Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in actual harm. Two nurse aides discovered a male resident, who had moderate cognitive impairment, in the bed of a female resident with severe cognitive impairment. The male resident was found naked, with his fingers inserted into the female resident's vagina, while the female resident was crying. The female resident's brief had been removed, and the incident was witnessed by multiple staff members. The female resident was subsequently transported to the emergency department, where a small tear was found on her labia during a forensic exam. Both residents involved resided on the locked memory care unit at the time of the incident. The facility's policy prohibits all forms of abuse, including sexual abuse, and defines sexual abuse as non-consensual sexual contact of any type. The incident was documented in staff witness statements and the facility's incident report, which detailed the discovery of the abuse and the immediate response by staff. The deficiency was cited under regulations requiring the facility to ensure residents are free from abuse and to provide adequate management and nursing services.