Failure to Protect Residents from Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving both resident-to-resident and visitor-to-resident abuse. In one incident, a severely cognitively impaired resident was found with another resident, who was moderately cognitively impaired, on top of him in bed, naked from the waist down and attempting sexual intercourse. Multiple staff members, including a CNA and LPNs, witnessed the event and had to physically remove the perpetrating resident, who was combative and had an erection. Despite the severity of the incident, there was no immediate documentation in the medical record, and the perpetrating resident remained in the facility without documented supervision until his discharge the following day. Staff interviews revealed confusion and disagreement about the nature of the incident, with some staff and administrators minimizing the sexual aspect, and others clearly identifying it as sexual abuse. The incident was not reported to law enforcement at the time, and statements from staff were either not collected or were delayed. Another incident involved a cognitively intact resident who reported to a family member that a frequent visitor had been inappropriately touching her during regular visits, including at facility activities such as bingo. The visitor admitted to the inappropriate sexual contact when confronted by a family friend. The facility's failure to recognize, evaluate, and restrict the visitor's access allowed the abuse to continue over an extended period. The resident expressed sadness, anxiety, and fear regarding the visitor's continued presence and the lack of intervention by the facility. The facility's policies required immediate investigation, documentation, and protective measures in response to allegations or suspicions of abuse. However, the investigation into the resident-to-resident incident was incomplete, with missing staff statements, lack of timely documentation, and no clear evidence of a thorough assessment of the victim. The abuse coordinator and administrator did not ensure that all required steps were taken, and there was a lack of communication and follow-up with staff and family members. The failure to implement adequate supervision and interventions for residents with known behavioral risks, as well as the failure to protect residents from abusive visitors, resulted in ongoing risk and emotional harm to vulnerable residents.