Failure to Protect Resident from Sexual Abuse Due to Inadequate Admission Screening
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. One resident, who had a history of hypersexual behavior following a stroke and was not cognitively intact (BIMS score of zero), was admitted to the facility from a hospital where his sexually inappropriate behaviors were documented. Hospital records indicated that the resident had been started on carbamazepine to address hypersexuality, and required interventions such as all-male nursing staff and a video sitter due to persistent inappropriate behaviors. Despite this, the facility's admission screening process did not fully identify or address these risks prior to admission. The facility's administrator later confirmed that, had they been aware of the extent of the behaviors, they would have taken additional precautions or reconsidered the admission. The incident occurred when a staff member observed the resident with his penis exposed, placing it on the lips of another resident who was nonverbal, unable to communicate, and cognitively impaired. The staff member immediately intervened and separated the residents. The victim was particularly vulnerable due to advanced dementia and inability to defend herself. Interviews with facility staff and review of records confirmed that gaps in the admission screening process contributed to the failure to protect the resident from abuse.