Failure to Supervise Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision, resulting in an incident of sexual abuse involving two residents with dementia. One resident, who had severely impaired cognition and was dependent on staff for all activities of daily living, was found in a wheelchair in the lounge area with another resident kneeling beside her and his hand inside her brief at the peri area. The incident was witnessed by a CNA, who observed the resident's hand entering the brief from the side and making contact with the peri area. The CNA described the resident's posture as appearing to enjoy the interaction, and the event occurred in a common area near the nurse's station. At the time of the incident, staffing in the area included a nurse passing medication and another CNA providing care in a different room, leaving the lounge area unsupervised. The resident who initiated the contact had impaired cognition but was physically able to move independently. The incident was discovered when the CNA exited another resident's room and observed the inappropriate contact. The written statement provided by the CNA was brief, as directed by the DON, but during a subsequent interview, the CNA provided more detailed observations about the nature and extent of the contact. The facility's investigation included review of witness statements, medical records, and interviews with staff. The administrator acknowledged the discrepancy between the CNA's written and verbal statements but maintained that the investigation did not indicate sexual abuse. However, the facility's policy required monitoring for sexually aggressive behavior and potential abuse in resident-to-resident altercations. The lack of supervision in the lounge area directly contributed to the incident, as staff were not present to prevent or immediately intervene in the inappropriate contact.