Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident incident involving inappropriate sexual contact. Two residents, both with severe cognitive impairment and court-appointed Conservators of Person (COP), were care planned to spend time together in the common area holding hands, as consented by their COPs. Both residents had a history of inappropriate sexual behaviors, and their care plans specifically prohibited intimate contact or being alone together in a room. Despite these interventions, staff observed one resident with their chest exposed and the other resident in contact with the exposed area in the common area. Staff interviews confirmed that the two residents were known to have a friendly relationship and often spent time together in the common area, holding hands as permitted. However, on the day of the incident, a nursing assistant witnessed inappropriate physical contact between the residents, which was not consented to by either the residents (due to their cognitive impairment) or their COP. The staff member intervened, and the resident involved became agitated and combative when redirected. Facility documentation and interviews with clinical staff, including the LPN, APRN, and Director of Nursing, confirmed awareness of the residents' cognitive limitations and the restrictions in place regarding their interactions. The facility's policy directed that residents be protected from abuse, including non-consensual sexual contact. Despite these policies and care plan interventions, the lack of adequate supervision allowed the incident to occur, resulting in a failure to protect the residents from abuse.