Failure to Prevent and Properly Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident sexual abuse between two residents, one of whom had known sexually inappropriate behaviors and one who was severely cognitively impaired. One resident had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was assessed as severely cognitively impaired, requiring extensive assistance or total dependence for most ADLs and unable to provide a reliable statement. The other resident had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in ADLs. This cognitively intact resident had a care plan documenting sexually inappropriate behaviors, including entering female residents’ rooms, with interventions such as anticipating needs and discussing inappropriate behavior. On the date of the incident, a CNA reported witnessing the cognitively intact resident standing in front of the cognitively impaired resident in the hallway with his pants halfway down and his genitals exposed, telling the cognitively impaired resident to look. When the exposing resident saw the CNA, he returned to his bedroom. The CNA stated she asked the cognitively impaired resident if the other resident had shown his genitals, and the resident responded yes. The CNA also reported overhearing the cognitively impaired resident later tell another CNA that she was scared. A prior nursing note documented that the same resident had indecently exposed himself to another resident in the hallway on a different date. The facility’s self-reported incident and internal investigation documented that the exposing resident’s pants appeared to be positioned below his waist but concluded there was no evidence of inappropriate conduct, unintentional harm, or adverse outcome, and the allegation of sexual abuse was unsubstantiated. The investigation did not include a witness statement from a nurse, and witness statements were not obtained from all staff involved. The Administrator later confirmed that he had reported that the resident’s pants were down and his genitals were exposed to the cognitively impaired resident, which was inconsistent with the conclusion in the submitted self-report, and acknowledged that sexual abuse could not be ruled inconclusive based on the investigation results. Facility policy defined abuse to include resident-to-resident altercations and identified sexual abuse as non-consensual sexual contact, with an expectation that residents’ capacity to consent would be determined and recorded.
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