Failure to Implement Abuse Prohibition Procedures
Penalty
Summary
The facility failed to implement its abuse prohibition procedures in response to an alleged sexual abuse incident involving two residents. On October 7, 2024, Resident 102 was observed holding Resident 289's hand on his genital region in the lunchroom. Despite the facility's policy requiring immediate reporting of such incidents, the administration and relevant authorities were not notified until October 9, 2024, two days after the incident. The facility's policy mandates that all allegations of abuse be reported immediately to the Charge Nurse, Director of Nursing (DON), Administrator, and the resident's physician, and that the incident be reported to the Department of Health and local police within two hours. However, these procedures were not followed, resulting in a delay in reporting and investigation. Resident 289, who was severely cognitively impaired and unable to consent to sexual activity, was not protected according to the facility's policies. There was no documentation of the incident in the clinical records of either resident, and no evidence that the facility's administrator, DON, attending physician, or the resident's responsible party were notified at the time of the incident. Additionally, the facility did not develop or implement a plan to prevent future occurrences and protect Resident 289 and other female residents from Resident 102's inappropriate behavior. The facility's failure to follow its abuse reporting and investigation policies was confirmed by a Clinical Operations Executive.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral for psychological services made for Resident 102 and an interdisciplinary approach continues. 2. Facility residents have the potential to be affected by deficient practice. The facility will identify other residents on the affected unit to assess their ability to consent. Any resident without the ability to consent will be monitored for safety. The facility will continue to conduct sex offender checks for new admissions prior to facility acceptance with completion of the Trauma Informed Care evaluation upon admission, to determine resident history of and risk for abuse. 3. Facility staff will be educated regarding Abuse and Neglect policies and procedures, specifically, the reporting guidelines upon hire and annually, focusing on immediate identification, reporting of abuse, and initiating interventions for monitoring and preventing recurrence by the facility. 4. Documentation and concern forms will be reviewed daily during the business week for four (4) weeks to identify any potential areas of concern then weekly until substantial compliance is achieved. Audit results will be submitted and reviewed by the Quality Assurance Performance Improvement committee.