Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with a known history of verbally abusive and sexually inappropriate behaviors was able to inappropriately touch another resident. The resident with these behaviors had diagnoses including vascular dementia, adjustment disorder, and anxiety, and was identified as having moderately impaired cognition. The care plan for this resident included interventions such as monitoring behaviors, redirection, removal from public areas when behavior was disruptive or unacceptable, and psychiatric follow-up as needed. Despite these interventions, the resident was observed by a student nurse with their hand under another resident's shirt, touching the upper chest area. The incident was reported and classified as inappropriate behavior. The resident who was touched also had dementia and moderately impaired cognition. The facility's Director of Nursing acknowledged that staff should have been vigilant in monitoring the resident with known behaviors to prevent such incidents. The facility's abuse policy defined sexual abuse as any unwanted touching between residents. The report did not identify whether the resident who was touched had the capacity to consent, nor did it explain why staff failed to monitor the location and behaviors of the resident with a history of inappropriate conduct, leading to the incident.