Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a non-verbal, severely cognitively impaired resident was not protected from sexual abuse by another resident, who was also the individual's father. The incident involved the father touching the resident's genital area in a public dining area, as witnessed by a CNA. The CNA observed the inappropriate contact and, instead of immediately intervening and separating the residents, went to notify a nurse. During this time, the inappropriate contact continued until the nurse arrived and confronted the resident, at which point the contact ceased. Documentation and interviews confirmed that the residents were not immediately separated upon the initial observation of the abuse. The resident who was the victim of the abuse had a history of traumatic brain injury, intellectual disabilities, and was dependent on staff for all activities of daily living, with documentation indicating she was non-verbal and unable to communicate her needs. The perpetrating resident had a documented history of inappropriate sexual behaviors, including making sexual comments and attempting to touch staff and other residents. Care plans for this resident included interventions such as not placing him near female residents and providing close supervision, but these interventions were not always consistently implemented, as evidenced by the incident. Additionally, there was a prior unreported allegation of sexual abuse involving the same two residents, where staff observed the perpetrator with his hand possibly inside the victim's brief. This previous incident was not reported to the State Agency, as facility leadership determined it was unsubstantiated due to lack of physical evidence and uncertainty from the observer. The failure to immediately intervene during the observed abuse and the lack of reporting of prior allegations contributed to the deficiency cited in the report.