Failure to Prevent and Monitor Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically resident-to-resident sexual abuse. One resident with a history of traumatic brain injury reported being touched inappropriately by another resident in a public area, which made her feel uncomfortable. Another resident, who had diagnoses including hemiplegia, vascular dementia with agitation, and cognitive communication deficit, reported that the same accused resident had entered her room multiple times, attempted to put his hand down her diaper, and ran his hands up her leg, causing her distress. Both residents were found to be cognitively intact based on their BIMS scores. The facility's investigation revealed that one of the residents had previously attempted to report inappropriate behavior but did not do so because the accused stopped at that time. The investigation did not include or implement ongoing monitoring to ensure the safety of the residents following these incidents. The administrator acknowledged that no plans for ongoing monitoring were developed after the abuse was reported, resulting in a deficiency related to the facility's failure to prevent and address resident-to-resident abuse.