Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and behavioral disturbances engaged in sexually inappropriate behaviors toward another resident. The incident took place in a common area, where the male resident, while in his wheelchair, approached a female resident who was also in a wheelchair. He lifted her blanket, raised her shirt, and inappropriately touched her breast, abdomen, and vaginal region. Staff intervened and separated the residents immediately upon noticing the event. The female resident, who had a BIMS score of 0, was unaware of the incident and showed no response when questioned. Following the initial incident, the same male resident was observed later that evening self-propelling in his wheelchair with his pants and protective underwear partially down, exposing himself to peers. Staff intervened by bringing him to his room, moving other residents away, and reminding him to stay covered. The facility's policies defined such actions as sexual abuse, specifically non-consensual sexual contact and unwanted intimate touching. The documentation and staff interviews confirmed that the facility failed to ensure residents remained free from abuse, as required by policy.