Failure to Protect Resident from Sexual Abuse
Penalty
Summary
A male resident with a history of Alzheimer's disease, hemiplegia, and moderate cognitive impairment was observed leaving the room of a female resident who was also moderately cognitively impaired and had diagnoses including hemiplegia, aphasia, and dementia. The female resident was found by staff with her gown pulled up and her brief unfastened on one side shortly after she was heard yelling. The male resident indicated he had gotten lost when questioned by staff. Upon assessment, the female resident was unable to verbally describe the incident but pointed to her breast, indicating inappropriate touching. This was the first reported incident of abuse involving the male resident. Staff interviews and record reviews confirmed that the male resident had previously exhibited sexually inappropriate behaviors and had a care plan addressing these behaviors. Despite this, he was able to enter the female resident's room and allegedly touch her inappropriately. The incident was documented as a reportable event, and the facility's policy on abuse prevention was reviewed as part of the investigation.