- Date
- 4/6/2025
- Report number
- 00393991-AP-345352
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On March 30, 2025, Alleged Victim (AV) was observed in the common area with Witness 1's (W1) hands inside AV's shirt. AV and W1 are both diagnosed with cognitive deficits which include confusion and AV is unable to protect AV's self. W1 had known inappropriate behaviors, and the facility failed to care plan according to those behaviors. Based on facility documentation and interviews, facility was aware of W1's sexual behavioral expressions on March 22, 2025, but did not initiate an alert until March 25, 2025. The facility alert did not include behavior monitoring, hourly safety checks, and a relocation to a different room/unit for W1 until April 8, 2025. The facility's failure to respond timely to W1's care needs exposed AV to sexual abuse. The facility failed to provide intermittent interventions, supervision, and staff support to mitigate W1's behavioral symptoms which ultimately led this incident in W1 made inappropriate sexual contact with AV causing AV emotional harm and unreasonable discomfort, which is considered a moderate violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00929 $1500.00 fine assessed