Failure to Supervise Leads to Resident-on-Resident Sexual and Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not protect a resident from both physical and sexual abuse by another resident. The incident occurred when a female resident, who had diagnoses including major depressive disorder and suicidal ideations, went to take a shower in the central shower room. While she was showering, a male co-resident entered the shower room without consent, despite the resident's verbal protests and demands for him to leave. The male resident used physical force, restraining the female resident against the wall, and sexually assaulted her. The assault was interrupted when another resident heard the victim's screams for help, entered the shower room, and then alerted staff, who intervened and separated the two residents. The investigation revealed that staff were expected to monitor the central shower area, especially given the facility's behavioral health population and the known risks associated with certain residents. On the day of the incident, the certified nursing assistant (CNA) assigned to monitor the shower area left his post to use the restroom without arranging for coverage, leaving the area unsupervised. Other staff members confirmed that coverage should have been arranged before leaving the monitoring area, and that there were other staff available to provide coverage if needed. The lack of supervision allowed the male resident, who had a documented history of aggressive and inappropriate behaviors, to access the shower room and commit the assault. Both residents involved had documented mental health diagnoses, and the male resident had a history of aggression and criminal charges, as well as care plans noting socially inappropriate and maladaptive behavior. The female resident was assessed as being at risk for abuse and had a care plan reflecting this risk. The facility's failure to ensure proper supervision and monitoring, as required by their own policies and procedures, directly led to the incident of abuse and resulted in significant physical and psychosocial harm to the victim.