Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to prevent sexual abuse between two residents in the hallway, as witnessed by staff on 12/18/2025. One resident, who had a history of cocaine dependence and moderate cognitive impairment, was observed pulling down his pants and exposing himself, while another resident, diagnosed with schizoaffective disorder and major depressive disorder, performed oral sex on him. Multiple staff members, including a dietary orientee and a CNA, witnessed the incident through a glass window and reported it to the charge nurse. The event was documented in the residents' records and confirmed through interviews with both residents and staff. Resident records indicated that one resident was considered self-responsible but had moderately impaired cognitive skills, while the other was not self-responsible and had a care plan for socially inappropriate and disruptive behaviors, including touching and kissing staff and residents. The care plan intervention was to observe the resident's behavior around others, but this was not specific enough to address the risk of sexual abuse. Prior to the incident, the resident with disruptive behaviors had also exhibited other inappropriate actions, such as throwing feces and attempting to touch or kiss others. Interviews with staff and residents revealed that the facility did not have a policy regarding consensual sexual relationships or acts between residents, nor could they provide documentation of consent for the sexual activity that occurred. The DON acknowledged that the care plan for the resident with disruptive behaviors was insufficient and not tailored to prevent sexual abuse. The facility's policy on abuse and neglect required prevention of all forms of abuse, including sexual abuse, but the measures in place were inadequate to prevent the incident between the two residents.