Failure to Protect Resident From Sexual Harassment by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual harassment by another resident, as required by its abuse prohibition policy. The facility’s policy, revised 11/28/19, states that residents must be protected from all forms of abuse, including sexual abuse and sexual harassment. One resident (R1) had a documented history and care plan problem area for multiple behavioral symptoms, including delusions, exit seeking, physical and verbal behaviors toward others, rejection of care, and making inappropriate comments toward female staff during care. R1’s cognitive status was documented as moderately impaired with a score of 10/15 on the MDS. Another resident (R2), with a cognitive score of 11/15 and no care plan problem areas indicating a history of making false allegations, reported that R1 made sexually explicit comments to her. On the morning of 1/8/26, R2 and R1 were both in the north dining room early, as R1 often went there for coffee and R2 had not been sleeping well and was also up early. R2 reported that R1 told her he wanted to see and touch her breasts in a sexual manner and made other graphic remarks. R2 stated she told R1 to stop talking to her that way, and he stopped immediately. R2 became upset, wheeled herself through the hallway looking for staff, and called out for help to report that R1 was making inappropriate comments and that she did not want other female residents to be harassed. Staff, including a CNA and an RN, responded to R2’s call, and R1 was escorted away from the area. During subsequent interviews, R2 consistently recalled the incident and reiterated that she was upset by R1’s comments and now makes a point to avoid him. Staff who knew both residents stated that both R1 and R2 were oriented to time, place, and purpose. The administrator later determined that the incident was not substantiated abuse based on a conclusion that R1 lacked capacity to understand his actions, despite also acknowledging that R1 understood basic social rules, could recognize that certain comments were inappropriate, and could follow simple directions or redirections. The facility’s determination that abuse was not substantiated, in the context of a credible report of sexually explicit comments and R1’s known history of inappropriate verbal behaviors, reflects the failure to ensure R2’s right to be free from sexual harassment by another resident.
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