Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident was found inappropriately touching another resident. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was discovered in bed in a fetal position, curled up and crying, with his penis exposed. Resident 2, who had a diagnosis of unspecified dementia and intact cognition per his MDS, was found sitting at the edge of Resident 1's bed with his pants or briefs pulled down, one hand under Resident 1's gown and the other on his own genital area. After the incident, Resident 1 was tearful and stated, "Get him away from me." According to IDT notes and staff interviews, CNA 1 and CNA 2 entered Resident 1's room for a recheck and observed Resident 2 at the end of Resident 1's bed with his pants or briefs down, his back to the door, and his hand extended toward Resident 1. CNA 1 reported seeing Resident 2 with his right hand on his own genitals and his left hand on Resident 1's hip, and when Resident 1's covers were pulled back, Resident 1's penis was exposed out of his brief. CNA 2 corroborated that Resident 2 had no brief or underwear on, his brief was on the floor, his right hand was under Resident 1's gown, and Resident 1's penis was exposed. The Assistant Director of Nursing stated she would consider this incident sexual abuse and affirmed that every resident has the right to be free from abuse, consistent with the facility's abuse policy stating that residents must not be subjected to abuse by anyone, including other residents.
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