SEATTLE, WA - A state inspection at Seattle Medical Post Acute Care revealed that a resident in a persistent vegetative state was sexually assaulted by their roommate, and facility staff failed to follow established protocols by not immediately sending the victim to the emergency room for evaluation and evidence collection.
Sexual Assault of Vulnerable Resident Discovered by Staff
On April 12, 2025, at approximately 3:00 PM, a certified nursing assistant entered a resident room and discovered a cognitively intact resident performing oral sex on their roommate who was in a persistent vegetative state. The victim, identified in the report as Resident 1, had been diagnosed with anoxic brain damage and had no visible consciousness or awareness of their surroundings.
According to the inspection report, Staff J, the certified nursing assistant, stated they observed Resident 2 "bending down at their waist and their head and face were in Resident 1's private area." The victim's incontinence brief had been unfastened, leaving their private area exposed. When the staff member called out to Resident 2 and asked what they were doing, the perpetrator stopped and walked back to their own bed.
The victim had been completely dependent on staff for all aspects of care and was unable to provide consent for any type of sexual contact. Their family member told investigators they "felt very scared when they were notified about the incident" and confirmed that Resident 1 was not capable of providing consent.
Following the discovery, the facility placed Resident 2 on one-on-one supervision. Law enforcement was contacted, and Resident 2 was arrested and removed from the facility that same day. The facility's investigation substantiated the resident-to-resident sexual abuse.
Critical Failure to Provide Emergency Medical Care
Despite the facility's own policy requiring victims of sexual assault to be sent to the emergency department for evaluation and evidence collection, staff failed to take this essential step. The facility's Investigation of Alleged Sexual Abuse policy specifically stated that residents should be sent "to the hospital emergency department for rape kit as indicated" and that evidence should be preserved.
The victim was not offered emergency room evaluation until two days after the assault occurred. When the responsible party was finally asked on April 14 if they wanted Resident 1 transferred for evaluation, they declined, stating "I didn't know what the whole situation was at that time."
The victim's family member confirmed that on the day of the incident, the facility did not ask or offer to transfer Resident 1 to the hospital for further evaluation. Multiple physicians involved in the case later stated they would have recommended immediate emergency room transfer.
Staff C, a physician, stated they "would have recommended to send Resident 1 to ER for evaluation after a sexual assault." Staff E, a physician assistant who examined the resident two days after the incident, stated "it would be most necessary and appropriate to send the resident to the ER as soon as it was discovered" and noted they hadn't been informed about the specific nature of the assault.
The on-call provider who was notified on the day of the incident, Staff D, revealed they received only limited information, stating that staff "were not comfortable disclosing what happened" when asked for details about the sexual inappropriate behavior.
Failure to Monitor and Address Aggressive Behaviors
The inspection revealed that Resident 2 had exhibited multiple concerning behaviors toward others in the months leading up to the assault, yet the facility failed to properly address these warning signs through care planning or ongoing monitoring.
Documentation showed Resident 2 had displayed the following behaviors between December 2024 and January 2025: - Threatening others (December 11) - Scratching and threatening others (December 18) - Pacing and wandering (December 20) - Grabbing others (December 29) - Wandering (January 3-4) - Physical aggression (January 15)
Despite these documented incidents of aggression toward others, the facility discontinued behavioral monitoring on January 25, 2025. The social services director acknowledged that while a social worker had met with Resident 2 about the grabbing incident, no care plan was developed to address these behaviors. Staff F stated the behaviors were not addressed in the care plan because there were "no behavioral trends" identified.
The Director of Nursing later admitted they were unaware of Resident 2's documented behavioral symptoms and acknowledged that behavioral monitoring had been discontinued when the resident was sent to the hospital and was not reactivated upon readmission.
Medical Significance of Protocol Violations
The failure to immediately transfer a sexual assault victim to the emergency room has serious medical and legal implications. Emergency departments are equipped to conduct comprehensive examinations that can identify injuries, collect forensic evidence, and provide prophylactic treatment for sexually transmitted infections. The Centers for Disease Control and Prevention guidelines emphasize that examinations should be conducted by experienced clinicians to minimize further trauma while making individual decisions about specimen collection for STI diagnosis.
Delaying medical evaluation by 48 hours significantly compromises the ability to collect viable forensic evidence. DNA evidence degrades rapidly, and the opportunity to document acute injuries may be lost. Additionally, the window for certain prophylactic treatments, including HIV post-exposure prophylaxis, which is most effective when started within 72 hours of exposure, becomes narrower with each passing hour.
For a victim in a persistent vegetative state who cannot report pain, discomfort, or other symptoms, immediate medical evaluation becomes even more critical. These individuals rely entirely on caregivers to identify and address potential injuries or infections that could result from assault.
Additional Issues Identified
The inspection also documented failures in basic hygiene care for other residents. Two residents who required assistance with toileting were found with bedside commodes and urinals that had not been emptied for extended periods.
One resident had a bowel movement that remained in their bedside commode from morning until at least 2:04 PM, despite the resident stating they had asked staff multiple times to empty it. Another resident was found with two urinals, one completely full and another half full, after waiting since morning for assistance.
The facility's own policies required bedside commodes to be emptied after each use, yet staff failed to provide this basic care. These incidents had been the subject of previous complaints, with one resident reporting waiting one to two hours for care after activating their call light.
Systemic Failures in Resident Protection
The violations identified at Seattle Medical Post Acute Care represent fundamental breakdowns in resident protection systems. The facility failed to recognize and respond to behavioral warning signs, failed to protect a completely vulnerable resident from sexual assault, and failed to follow established medical protocols after the assault occurred.
The Director of Nursing's admission that they were unaware of documented aggressive behaviors and the discontinuation of behavioral monitoring without proper reassessment indicate systemic problems with communication and care planning. When facilities fail to track and address concerning behaviors, they create environments where vulnerable residents remain at risk.
The two-day delay in offering emergency medical evaluation not only violated the facility's own policies but also potentially compromised both medical treatment and criminal investigation. The fact that multiple staff members, including the Executive Director, acknowledged that sexual assault victims should be immediately sent for emergency evaluation makes the failure to do so particularly troubling.
These violations demonstrate how multiple system failures can converge to create situations where the most vulnerable residents face harm. Residents in persistent vegetative states depend entirely on facility staff for their safety and protection, making the facility's failures in this case especially severe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seattle Medical Post Acute Care from 2025-05-02 including all violations, facility responses, and corrective action plans.
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