Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident inappropriately touched them. Resident #1, who had diagnoses including Down syndrome and cerebral infarction, had a BIMS score of 02, indicating severe cognitive impairment and a need for partial to moderate assistance with all ADLs except eating. On 01/25/26 at 8:00 p.m., Resident #1 approached nursing staff, gestured to their breast, and pointed to Resident #2, indicating that Resident #2 had grabbed their breast. A late entry nursing progress note documented this report on 01/26/26 at 8:09 p.m. Resident #2 had a significant change assessment showing a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses including congestive heart failure, end stage renal disease, and diabetes mellitus. Resident #2 required set-up assistance for oral hygiene, toileting, showering, and partial to moderate assistance with personal hygiene. A care plan dated 01/25/26 identified a problem of behavioral symptoms with a history of socially inappropriate and/or disruptive behavior, with approaches that included allowing distance in seating from other residents and intervening to ensure all residents felt safe as necessary. Despite this identified behavioral history and care plan, Resident #2 was able to position their wheelchair next to Resident #1 and make physical contact with Resident #1’s breast. A final incident report, supported by review of facility camera footage, confirmed that Resident #2 pulled their wheelchair beside Resident #1, lifted Resident #1’s blanket, and placed their hand on Resident #1’s breast. This event demonstrated that Resident #1 was not kept free from abuse by another resident. At the time of the survey, Resident #1 was observed interacting pleasantly in the common area, and Resident #2 was observed under one-on-one supervision, but the documented incident and video evidence showed that the facility did not prevent the abusive contact from occurring between the two residents.
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