Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Visitor
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's disease with dyskinesia, and total dependence on staff for mobility and personal care was subjected to repeated inappropriate touching by a visiting assisted living resident over approximately 38 minutes. The resident was unable to consent or protect herself due to her medical condition, which included dementia and physical limitations. The incident occurred in a common area, where the perpetrator lifted the resident's skirt and made skin-to-skin contact with her thighs and vaginal area multiple times, as captured on facility surveillance footage. Staff present in the area observed unusual behavior, such as the perpetrator watching staff closely and remaining near the resident, as well as the resident's skirt being repeatedly bunched up. Despite these observations and suspicions of inappropriate contact, staff did not intervene to remove the perpetrator or the resident from the situation. One staff member pulled the resident's skirt down several times but did not take further action, citing uncertainty about how to handle the situation and fear of the perpetrator's reaction. The incident was not immediately reported to facility leadership, and the administrator and DON were only notified the following day. Interviews with staff revealed a lack of clarity regarding their responsibilities in suspected abuse situations, with some staff expressing uncertainty about the resident's ability to make decisions and discomfort with the situation. The failure to intervene and report promptly allowed the inappropriate contact to continue for an extended period, leaving the resident unprotected despite her vulnerability and care plan identifying her as at risk for abuse or neglect.
Removal Plan
- Education for all staff covering definitions and types of abuse, staff responsibilities for prevention and reporting, mandatory reporting timelines and procedures, internal facility reporting process, resident rights and protections, zero-tolerance policy and disciplinary actions
- AP banned from facility
- Assessment of R1 for injury and mental anguish as able