Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse perpetrated by another resident. One resident with severe cognitive impairment and a history of inappropriate sexual behaviors, including wandering into other residents' rooms and making sexual remarks, was not adequately supervised despite documented ongoing incidents. The care plan for this resident included interventions such as redirection, medication, and seating arrangements to minimize inappropriate behaviors, but these measures did not prevent further incidents. Documentation showed that the resident continued to enter female residents' rooms and make inappropriate comments and contact, even after staff interventions and care plan revisions. On the evening of the incident, the resident entered a room shared by two female residents, both with cognitive impairments, and sat on one resident's bed while she was sleeping. He then touched her breast, causing her significant distress. The roommate, who was cognitively intact, witnessed the event, yelled at the perpetrator to leave, and reported the incident to her daughter. The affected resident was visibly upset, crying, and shaken after the event. Multiple staff and family interviews confirmed the sequence of events, and documentation indicated that the resident responsible for the abuse had a known pattern of similar behaviors that had not been effectively managed. Staff statements and interviews revealed that supervision of the resident with a history of sexual behaviors was inconsistent. Although one-to-one supervision was implemented after the incident, prior to the event, the resident was able to access other residents' rooms without adequate oversight. The facility's failure to provide continuous and effective supervision, despite clear documentation of risk and previous incidents, resulted in a resident being subjected to sexual abuse.