Failure to Prevent Resident-to-Resident Sexual Contact at Nursing Station
Penalty
Summary
The facility failed to prevent a resident-to-resident sexual altercation, contrary to its Abuse-Prevention policy, which required prevention and prohibition of all types of abuse and protocols to prevent sexual abuse. Resident 1, who had Alzheimer's disease with severe impaired cognition and was dependent on one to two staff for ADLs, was involved in an incident with Resident 2, who had intact cognition, diabetes, COPD, heart failure, and required supervision or was dependent for ADLs while using a wheelchair for ambulation. The facility’s investigation report documented that on 02/04/2026, Resident 1 walked up to Resident 2 at the Team 3 nursing station and grabbed Resident 2’s left breast. Staff and resident interviews further described the event. Staff L, an LPN, stated they were present when Resident 2 spoke to Resident 1, after which Resident 1 reached out and squeezed Resident 2’s left breast; Staff L then removed Resident 1 from the situation and assisted them back to their hall and into a chair. Resident 2 reported that while at the nurse’s station, Resident 1 reached out and grabbed their left breast, and that they responded by telling Resident 1 not to do that and not to touch their breast, pushing Resident 1’s hand away. Resident 2 stated they felt angry and violated during the altercation. The DON later confirmed that Resident 2 did not have intent for Resident 1 to touch them and that the contact was unwanted, constituting an abusive incident under the facility’s abuse-prevention requirements and WAC 388-97-0640(1).
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