Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to ensure a safe environment free from sexual abuse. One male resident with a history of traumatic brain injury, vascular dementia, and severe cognitive impairment was known to engage in sexually inappropriate remarks and uninvited physical contact with female staff. Despite these documented behaviors and care plan interventions, the resident was able to place his mouth on the breast of a female resident in a common area. The incident was witnessed by a staff member, who immediately separated the residents. The male resident's care plan included interventions such as redirection, staff accompaniment for female employees, and analysis of behavioral triggers. However, these measures did not prevent the incident from occurring. The female resident involved had a history of trauma, including past sexual abuse, and also had severe cognitive impairment. Her care plan noted her risk for re-traumatization and included interventions for trauma processing and psychosocial support. At the time of the incident, both residents were in the dining room, and the female resident was found with her shirt lifted and the male resident's mouth on her breast. Following the incident, both residents were evaluated and found to have no new injuries, though the female resident had a pre-existing bruise on her breast. The event was reported to facility administration, the attending physician, and the residents' contacts. The incident was also reported to law enforcement. The deficiency centers on the facility's failure to prevent the male resident, who had a known history of sexually inappropriate behavior, from having unsupervised access to other residents, resulting in sexual abuse of another cognitively impaired resident.