Failure to Prevent Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, resulting in multiple incidents involving a male resident who inappropriately touched female residents on several occasions. The male resident, who had severe cognitive impairment and a history of sexually inappropriate behaviors, was observed by staff touching the breasts and thighs of female residents, some of whom also had severe cognitive impairment and were unable to advocate for themselves. These incidents occurred in various locations within the facility, including hallways, the dining room, and resident rooms, and were witnessed by CNAs and reported to nursing staff. Despite the initial incident of sexual abuse, the facility did not implement effective measures to prevent further occurrences. The male resident continued to have access to vulnerable female residents, and additional incidents of inappropriate touching were documented over several months. Staff interviews revealed that the male resident would sometimes offer snacks to other residents as a means of interaction, and that supervision and monitoring were inconsistent. Care plans for the involved residents noted their cognitive impairments and wandering behaviors, but interventions to prevent abuse were not adequately enforced or updated in a timely manner following each incident. Documentation and interviews indicated that staff were aware of the male resident's behaviors and the risks posed to other residents, yet failed to consistently separate him from potential victims or provide sufficient supervision. The facility's policies required protection from abuse, but these were not effectively implemented, resulting in repeated incidents. The failures placed residents at risk of abuse, mental anguish, and fearfulness, as confirmed by the survey findings.