Failure to Prevent Resident-to-Resident Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving residents with cognitive and physical impairments. In the first incident, a female resident with a history of cerebral infarction, major depressive disorder, muscle wasting, and impaired mobility, who was not cognitively intact, was sexually assaulted by another resident. The perpetrator, who also had cognitive impairment and behavioral issues, approached the female resident in the dining room, made an inappropriate sexual comment, and groped her breast. This event was witnessed by an LPN, who observed the inappropriate contact and intervened to separate the residents. The incident was substantiated as sexual misconduct based on consistent staff accounts and documentation in the facility's investigation report. In the second incident, another resident with cognitive impairment, a history of traumatic brain injury, and limited mobility was physically assaulted by the same resident involved in the first incident. The administrator witnessed the perpetrator strike the other resident on the head with an open hand in the dining room. The two residents then engaged in a physical struggle, which was immediately broken up by the administrator. Both residents involved in this incident had cognitive deficits and required assistance with activities of daily living. There were no obvious injuries reported as a result of the altercation. Both incidents were documented in the facility's investigation reports and were reported to the appropriate authorities, including the residents' power of attorneys, police, and medical doctors. The facility's abuse policy states that every resident has the right to be free from abuse and that abuse is prohibited. Despite this policy, the facility failed to prevent these incidents of sexual and physical abuse between residents with known behavioral and cognitive issues.