Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with a history of sexually inappropriate behaviors. This resident, who was cognitively impaired and had a history of sexual dysfunction, engaged in multiple incidents of inappropriate sexual behavior towards other residents. Despite being on 15-minute checks, the resident continued to exhibit behaviors such as touching other residents inappropriately, exposing themselves, and masturbating in common areas. The facility did not have effective interventions in place to prevent these behaviors from recurring, and there was a lack of timely assessment and documentation of the incidents. The incidents involved multiple residents, including two identified residents who were cognitively impaired. One resident was touched inappropriately on the breast, and another had their back and buttocks rubbed. There were also several unidentified residents who were exposed to the inappropriate behaviors. The facility's policies required immediate steps to ensure resident safety and to provide medical attention when necessary, but these were not effectively implemented. There was a lack of timely notification to the provider and the residents' families, and the care plans were not updated promptly to address the ongoing issues. The facility's failure to document and assess the impact of these incidents on the affected residents further contributed to the deficiency. Staff interviews revealed that incident reports were not consistently completed, and there was confusion about the responsibilities for assessing and documenting the incidents. The facility's Corporate Director of Nursing acknowledged that incident reports should have been initiated immediately, and assessments should have been conducted by a registered nurse. However, these actions were not consistently carried out, leading to a failure to protect residents from further abuse.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 F 600 483.12 Abuse and Neglect 1. Immediate Corrective Action: - Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. - Resident #2 was discharged from Valley View Manor on 3/26/24. - Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident #1. Resident #5 stated that I just ignore him or move away if I find myself too close to him. Resident #1 has not engaged with me since our encounter previously. - Resident #1 had his care plans reviewed on 12/20/24. No revisions are currently needed. Interventions will include, 1:1 monitoring following any incidents, ongoing medical review to focus on medication management to address any underlying conditions contributing to behavioral issues. Will continue with routine psychiatric evaluations and adjust treatment plans as needed. - Resident #1 refused to be seen by the psychiatrist on 12/5/24, was sleeping when the psychiatrist attempted to see him on 12/19/24 and is scheduled to be seen 1/2/24. - There are no updates regarding resident #1 transfer to an all-male unit or another facility, However the facility actively investigating all available options. - LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/24. - LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: - The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. - The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: - The facility will conduct the following to prevent this practice from occurring in future: - Abuse Prevention and Reporting Policy was reviewed with revisions to include: - Investigation: - victim and aggressor assessment, - obtaining statements from involved residents and witnessing residents, - Resident statements will be attempted despite cognitive status - All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. - The following information must be available for the investigators upon request: - All statements obtained - The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. - Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: - The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: - The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025.