Complaint Investigation Report

A resident was inappropriately touched by another resident due to neglect and lack of supervision:

The allegation is that the facility neglected and lack of supervision resulting in a resident wandering to another resident's room and inappropriately touching another resident.

On 11/15/2023, LPA interviewed Executive Director (ED) Marrife Duewel. ED stated on 10/24/2023 around 2:00PM, resident R1 entered resident R2's room without permission. R1 exposed self to R2. and asked for oral sex. R1 inappropriately touched R2's breast and private areas. R2 asked R1 to stop. R1 stopped and left the room. ED stated he/she went to resident R2's room immediately after he/she received the report. ED stated he/she saw R1 walked down the hallway away from R2's room. ED stated no injury noted on resident R2 after the facility staff assessed R2.

ED stated after the incident, all staff were instructed to closely monitor R1's behavior and to ensure residents' safety. ED stated the facility notified R1's POA to come to the facility for a care conference on 10/24/2024, at 6:00PM. ED stated the facility notify R1's doctor the incident and to work on R1's medications.

ED stated after the incident, R1's doctor prescribed new medications for R1. R1 was provided a 1:1 private caregiver and R1 goes home with R1's family after dinner or R1' family to keep R1 company at night in the facility. ED stated the facility is working with R1's family to move R1 to another facility on the coming weekend.

LPA interviewed staff S1. S1 stated he/she sometimes saw R1 watching porn video in his/her room, and brought the concern to R1's care conference before this incident. S1 stated sometimes he/she saw R1 wandering in the hallway. S1 stated he/she asked caregivers to watch R1. S1 stated R1 did not have sexual incident before. S1 stated he/she knows some residents lock their door, but he/she know R2 does not lock the door.

LPA interviewed staff S2. S2 stated R1 and R2 are friends in the facility. S2 stated R1 and R2 sometimes have lunch or dinner together at the same table. S2 stated R1 and R1 did not have any inappropriately behavior before. S2 stated R1 usually go home with family on weekend or on holidays. S2 stated R1's care plan should be update to have more supervision and monitoring.