Failure to Protect a Resident From Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. The resident, who had Parkinson's disease with dyskinesia, dysphonia, muscle weakness, and intact cognition per a recent MDS (BIMS score 13), was dependent on staff for care and had contracted limbs. On one occasion, a licensed nurse entered the resident's room and observed an unlicensed staff member standing beside the resident, with his pants pulled down in the front, holding his exposed penis in his hand. The nurse saw his penis pressed against the resident’s left buttock at the gluteal fold while his other hand was on the resident’s left buttock. The resident was lying on her bed with her legs contracted, positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed where the unlicensed staff member was standing. Following this event, the business office manager was informed and interviewed both the licensed nurse and the unlicensed staff member. The unlicensed staff member did not deny having his penis exposed in the resident’s room and responded, "I don't know" and "whatever she said" when asked about the allegation. The resident later reported that the unlicensed staff member had been inappropriate with her, that he did things she did not want him to do, and confirmed that he had inserted two to three fingers into her vagina when cleaning her and had put his penis in her vagina more than once, despite her saying no. A charge nurse reported that the resident stated "boundaries were crossed" during personal care, that the staff member sometimes pushed his fingers on her anus, was rough, and lingered too long in her room. A police detective stated that the resident reported multiple instances of the staff member touching her with his penis and inserting his penis and fingers into her vagina, and that the staff member admitted to touching the resident inappropriately with his penis and fingers on multiple occasions. This conduct occurred despite a facility policy stating a zero-tolerance stance toward any form of resident abuse.
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