Failure to Prevent Repeated Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident with a known history of sexually inappropriate behavior inappropriately touched the resident’s lower private area in a unit day room. On the date of the incident, an Activities Aide walking by the South Unit day room observed one resident in a wheelchair positioned beside another resident’s chair and touching the other resident’s lower private area. The staff member immediately intervened, separated the residents, and notified the nurse. Both residents were assessed and found without injuries. The resident who was touched had been admitted with diagnoses including Alzheimer’s disease and major depressive disorder, and a recent MDS assessment documented severe cognitive impairment. Record review showed that the resident who engaged in the touching had an existing care plan, initiated months earlier, addressing a history of sexually inappropriate behavior and inappropriate touching of other residents and staff. The care plan documented multiple prior incidents of inappropriate touching involving other residents, including two earlier incidents with the same cognitively impaired resident. Despite these prior events and care plan focus, the resident continued to engage in inappropriate touching. Documentation also showed a discrepancy between the location recorded on a 15‑minute observation sheet, which indicated the resident was at the nurse’s station on a different unit at the time of the incident, and the actual location of the incident in the South Unit day room. During interview, the Administrator acknowledged the prior inappropriate touching incidents involving these residents and the implementation of interventions but could not provide evidence that the affected residents were kept free from abuse by the resident with sexually inappropriate behavior.
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