Failure to Prevent and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent inappropriate sexual behavior between them. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric issues were left unsupervised in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the breast of the other over her clothing. The CNA also noted that the female resident's bra was around her waist and she was not wearing a brief. Prior to this incident, the male resident had been documented as exhibiting increasingly erratic and intrusive behaviors, including entering other residents' rooms, being verbally aggressive, and being difficult to redirect. These behaviors were noted by multiple staff members and documented in progress notes, but no effective interventions or increased supervision were implemented to address the escalating risk. Despite clear documentation of the male resident's behavioral changes and repeated incidents of him entering other residents' rooms, staff did not provide adequate supervision or take preventive measures. The incident in the dining room was not properly documented in the residents' progress notes, and there was no notification to the physician or the designated representative regarding the sexual abuse incident. The facility's incident reports for the relevant period did not include this event, and the initial internal investigation discounted the CNA's account due to perceived inconsistencies, leading to a determination that no abuse had occurred. As a result, both residents remained on the same locked unit without additional monitoring or safeguards in place. Interviews with staff and review of facility records revealed a lack of immediate protective actions and failure to follow abuse prevention policies. The administrator and DON did not take action after being notified of the incident, and the male resident was not placed under increased supervision until after the event was identified by surveyors. The nurse practitioner was not informed of the potential sexual abuse, and there was no evidence of timely or appropriate notification to medical providers or family members. This series of inactions and failures to document, report, and intervene placed other residents at risk of abuse and neglect.