Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that a resident was protected from sexual abuse by another resident during dinner service in the dining room. One resident, a male with a history of cerebral infarction and severe cognitive impairment (BIMS score of 1), was observed by the Social Services Director (SSD) to have another resident, a female with Alzheimer's disease and also severe cognitive impairment (BIMS score of 6), touching his genital area over his pants. The SSD noticed the incident after making eye contact with the male resident, who appeared surprised, and upon further observation, saw the female resident's hand moving on top of his genital area. The SSD immediately intervened and separated the two residents. Interviews with facility staff, including the SSD, DON, and ADM, revealed that none of them believed the contact constituted sexual abuse, citing the lack of intent for sexual gratification and the belief that both residents could consent to sexual activity. The SSD and DON both stated that the male resident could communicate his needs and emotions, and the psychiatric services social worker noted that he felt safe at the facility, though he became defensive when asked about the incident. The female resident did not recall the incident and denied any inappropriate behavior. The facility's policy defines sexual abuse as non-consensual sexual contact of any type with a resident. Despite this, staff did not recognize the incident as sexual abuse and did not identify it as such in their responses. The incident was reported to the administration, but the staff's interpretation of the event did not align with the facility's written policy regarding abuse and resident protection.