Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two cognitively impaired residents and another resident who was cognitively intact but had intellectual disabilities. On the day of the incident, one resident was found in another resident's room with his pants down and an erect penis, while the cognitively impaired resident was sitting on the bed with saliva on his face and mouth. Later that same day, another cognitively impaired resident was found with feces and blood on his shirt and incontinence brief, which appeared to have been tampered with, while the same perpetrating resident was in the room with feces and blood on his hands, performing self-gratification of his rectum. The affected resident indicated to police that the perpetrator had manipulated both his own and the victim's penis in a sexual manner, despite the victim's attempts to resist and call for help. Staff observations and interviews revealed that the incidents were not immediately recognized or reported as sexual abuse. Staff initially believed the interactions may have been mutual or related to behavioral issues, and did not want to embarrass the residents. The events were reported up the chain of command as concerns about hygiene, infection prevention, or behavioral issues, rather than as potential sexual abuse. Documentation in the clinical records was incomplete, lacking details about the events and failing to address the condition of the residents' genitals or rectum. The facility's abuse prevention policy required immediate notification of the Administrator, DON, and Social Services Director, as well as appropriate documentation and reporting to state agencies, but these procedures were not fully followed at the time of the incidents. The residents involved had significant cognitive and physical impairments, with one being non-verbal and dependent for care, and the other having moderate cognitive impairment and requiring supervision for activities of daily living. The perpetrating resident was cognitively intact but had a history of intellectual disabilities and behavioral issues, including a tendency to insert objects into his rectum. Despite these known risks, there was no care plan addressing sexually inappropriate behaviors, and staff did not implement adequate interventions to prevent recurrence. The facility's failure to recognize, document, and report the incidents as abuse, as well as the lack of comprehensive behavioral interventions, led to the deficiency.