- Date
- 4/4/2024
- Report number
- 00323119-AP-274920
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a resident of the facility and receives care due to short-term memory loss, which places AV at risk of harm because of difficulty recalling information and susceptibility to manipulation. Alleged Perpetrator 2 (AP2), employed as a caregiver at the facility, entered into an inappropriate and prohibited relationship with AV. AP2 was discovered in AV’s bed by a member of facility management and was immediately suspended. During the internal investigation, both AV and AP2 denied any inappropriate relationship. AP2 was later reinstated but restricted from working on AV’s floor or providing care to AV. Despite these restrictions, AP2 continued visiting AV’s room and maintained communication via text messages. While AV was hospitalized between March 16, 2024, and March 27, 2024, AP2 disclosed to Alleged Perpetrator 3 (AP3) that AP2 had “kissed” AV. Between February 13, 2024, and April 2, 2024, AP2 engaged in a texting relationship with AV that included: sexual photos and explicit language; use of pet names and inappropriate emojis; and manipulative language when AV did not respond. When AV stopped responding, AP2 continued sending inappropriate messages. AV was initially reluctant to discuss the relationship but later disclosed that it was intimate, both physically and emotionally, and expressed that AP2 was “playing mind games.” AV stated he/she ended the relationship when he/she no longer wished to continue. Although the facility provides mandatory reporting training and all interviewed staff confirmed completion, multiple staff members were aware of and uncomfortable with AP2’s actions yet failed to report or adequately follow up. This indicates that the training was insufficient to ensure timely intervention and prevention of inappropriate conduct. AP2's actions caused AV significant emotional harm. AP2's actions is considered sexual abuse. The facility’s failure to properly monitor AP2 while caring for residents and failing to train staff on proper mandatory reporting guidelines resulting in sexual abuse by AP2 is a violation of resident rights is considered neglect of care and constitutes abuse. Given AV’s cognitive impairment and the inherent power imbalance between resident and caregiver, this situation presents an elevated risk of further harm. Alleged Perpetrator 3 (AP3) failed to follow mandatory reporting requirements when informed of inappropriate intimate physical contact made by AP2 towards AV, resulting in ongoing sexual abuse by AP2. AP3's action is considered neglect of care which constitutes abuse. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 5 (AP5) allegedly neglected AV. An investigation determined no abuse occurred by AP4 and AP5.
- Sanction
- RCFCP26-00165 $2500.00 fine assessed