Failure to Prevent and Address Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically failing to implement and update care plans and interventions after multiple incidents of sexually inappropriate behavior by a resident with a history of cerebral infarction and vascular dementia. Despite documented incidents where this resident engaged in inappropriate touching and behavior towards other residents, there was no evidence that the care plan was revised or that effective interventions were put in place to prevent further abuse. The care plans in place included general monitoring and support, but did not address the specific behaviors or provide targeted strategies to protect other residents after each incident. On several occasions, the resident was observed engaging in or attempting sexually inappropriate acts with other residents, including an incident where the resident was found half-naked on top of another cognitively impaired resident, with their mouth on the other resident's genital area. Staff interviews and documentation revealed that after these incidents, the resident's care plan was not updated to reflect new interventions, and there was no evidence of consistent 1:1 monitoring or other measures to prevent recurrence. Additionally, after being moved to a different unit, the resident was able to return undetected to the original resident's room, indicating a lack of effective supervision and monitoring. Documentation gaps were also noted, as some incidents were not recorded in the residents' progress notes, and there was confusion among staff regarding protocols for monitoring and updating care plans. Interviews with staff and administration confirmed that protocols for separating residents, notifying physicians, and transferring residents to the hospital were not consistently followed. The failure to implement adequate interventions and update care plans after repeated incidents resulted in a situation of Immediate Jeopardy and substandard quality of care, with a likelihood of serious harm to the residents involved.