Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by other residents, resulting in actual harm. In one incident, a resident with dementia and impaired cognition, who required supervision for mobility and had a history of hallucinations and wandering, was assaulted by his roommate. The assault involved inappropriate physical contact, choking, and digital penetration, resulting in physical injuries such as abrasions, scratches, a sore throat, and rectal tenderness. The resident was assessed by staff, transferred to the hospital for evaluation, and law enforcement was notified. Despite the evidence and the resident's account, the facility's self-reported incident documentation indicated the event was unsubstantiated due to insufficient evidence. In another incident, a resident with Alzheimer's disease and anxiety disorder, who was cognitively intact and independent in activities of daily living, was subjected to unwanted sexual advances by another resident known to have a history of attempting sexual activity with peers. The aggressor entered the resident's room, refused to leave when asked, and proceeded to pull down the resident's clothing and touch him inappropriately. Staff intervened and separated the residents, and both were placed on frequent checks. The facility was aware of the aggressor's prior behaviors and had previously attempted to manage them with medication changes and provision of a pleasure device. The facility's policy defined abuse and outlined procedures for assessment and reporting, but the incidents demonstrate a failure to prevent and protect residents from abuse by peers. Both incidents involved residents with cognitive impairments or behavioral histories, and in both cases, the facility did not prevent the abusive events despite prior knowledge of risk factors.