Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
A cognitively impaired male resident with a documented history of sexually inappropriate behaviors was observed inappropriately touching a cognitively impaired, non-verbal female resident in a lounge area. The male resident had prior incidents of sexually charged behavior, including attempts to touch female residents and staff inappropriately, and was known to be able to move himself in his wheelchair despite staff attempts to position him in a recliner for safety. On the day of the incident, staff left the male resident in his wheelchair in the lounge with female residents present, contrary to his care plan interventions, which included increased supervision and physical separation from female residents due to his behavioral history. The female resident involved was non-verbal, severely cognitively impaired, and fully dependent on staff for all activities of daily living, making her unable to defend herself or communicate consent. Staff observed the male resident with his hand inside the female resident's shirt, fondling her breast. The incident occurred when a CNA left the male resident unattended in his wheelchair near the female resident while assisting another resident, despite being aware of his history of inappropriate sexual behavior. The nurse on duty was not immediately informed of the incident, and there was a delay in reporting to facility leadership. The facility's policy required the prevention of abuse and the deployment of sufficient, trained staff to meet residents' needs and prevent abuse. Despite this, the male resident's known behaviors were not adequately managed, and staff failed to follow established interventions, resulting in the female resident being subjected to sexual abuse. The incident was witnessed by staff, and subsequent interviews confirmed that staff were aware of the male resident's behavioral risks but did not consistently implement the required precautions.