Failure to Protect Resident From Sexual Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to ensure a resident’s right to remain free from sexual abuse when one cognitively intact male resident engaged in inappropriate physical contact with a severely cognitively impaired female resident. On the afternoon of 12/27/25, while visiting another resident in the same room, the male resident rubbed the female resident across her thigh and belly. The female resident, who had a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired cognition and a diagnosis of schizophrenia, later reported that he rubbed her leg on the outside of her thigh and the side of her breast, and that she told him to stop, at which point he stopped and left the room. She denied any skin-to-skin contact. Another severely cognitively impaired resident in the room reported witnessing the male resident rubbing the female resident and pointed to her groin area. The male resident, who had a BIMS score of 15 indicating no cognitive deficits, acknowledged rubbing the female resident across the thigh and belly. The incident was not reported to facility administration at the time it occurred. A CNA observed the male resident in the female resident’s room with his hand in her brief and his mouth on her breast on the afternoon of 12/27/25 but did not immediately report this allegation of sexual abuse. The Administrator did not receive the allegation until 12/31/25 at approximately 3:00 PM, at which time the investigation was initiated. The delay in reporting and response, combined with the observed and reported inappropriate physical contact between the residents, constituted the failure to protect the resident from sexual abuse as required by the facility’s abuse prohibition policy.
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