Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure appropriate supervision and implementation of interventions to prevent resident-to-resident sexual abuse. Specifically, a cognitively impaired resident with a Brief Interview for Mental Status (BIMS) score of 11 was observed engaging in sexual activities with another resident who had a BIMS score of 0, indicating severe impairment for decision-making. The incident occurred behind closed doors, where a Certified Nurse's Aide (CNA) witnessed the cognitively impaired resident performing oral sex on the severely impaired resident. Both residents were known to have impaired cognition and were on 30-minute visual checks due to their behaviors. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including non-consensual sexual contact. Despite this, the facility did not adequately evaluate the residents' capacity to consent to sexual activity, as both residents were confused and unable to consent. The incident was reported to the Nursing Supervisor, and both residents were placed on one-to-one supervision. The Director of Nursing and the Administrator acknowledged that both residents had impaired cognition and were not capable of consenting to sexual activities.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 Hempstead Park Nursing Home P(NAME) F689 1. Immediate Correction: 1) On 2/03/2025 the DNS reviewed plan of care for Resident # 1 to ensure that all measures were in place to provide adequate supervision to prevent any future incidents of sexual abuse. The P(NAME) included redirecting residents to high visibility areas, day room monitoring, re-direction of peers from entering room, ensuring that room door is always kept open, staff education on special care needs, monitoring and reporting of inappropriate sexual behaviors, psychological services, and regular psychiatric evaluations. 2) On 2/03/2025 the DNS reviewed plan of care for Resident # 2 to ensure that all measures were in place to provide adequate supervision to prevent any future incidents of sexual abuse. The P(NAME) included redirecting residents to high visibility areas, day room monitoring, re-direction of peers from entering female rooms, ensuring that room door is always kept open, staff education on special care needs, monitoring and reporting of inappropriate sexual behaviors, Resident 1 to remain on psychological service and regular psychiatric evaluations for both residents. II. Identification of Others: 1) The facility respectfully states that all residents with impaired cognition could potentially be at risk for sexual abuse. 2) A list of all residents that triggered for behaviors of wandering and inappropriate behaviors towards others was generated from MDS data submitted in the last 90 days. 3) A list of all residents that display or displayed inappropriate sexual behaviors was obtained from RN Unit Manager for each floor. 4) The identified residents were audited to ensure that a plan of care was in place to provide adequate supervision to prevent incidents of sexual abuse: to include enhanced monitoring, day room supervision, staff education, and awareness. III. Systemic Changes: 1) The DNS and ADMIN reviewed the Policy and Procedure for Accident and Incidents, and found same to be in compliance. 2) The DNS and ADMIN reviewed the Policy and Procedure on Abuse and found same to be in compliance. 3) All Nursing Staff will receive In-service Education by the In-service Coordinator on the need for adequate supervision and interventions to prevent resident to resident sexual abuse. Highlights of the Lesson Plan include: - The definition of sexual abuse - The responsibility to supervise and safeguard residents with behaviors in order to prevent abuse - Resident behaviors that indicate a sexual preoccupation - Residents that have a history of sexually inappropriate behaviors - Residents that display signs of affection towards peers - The responsibility of staff to communicate any of the above behaviors to the Charge Nurse - The responsibility of the IDT to review these behaviors and the interventions that will provide adequate supervision and safeguarding to prevent sexual abuse - The importance of re-directing residents that wander to a common area and the need to engage them in activities - The need to ensure that resident room doors are open unless otherwise care planned for - The importance of having cognitively impaired residents meet in a common area rather than in their rooms - The responsibility of the IDT to identify residents that have a friendship with each other and implement a plan of care for this. - The process involved in care planning when 2 residents are able to consent to sexual intimacy IV. Quality Assurance: 1) The DNS developed 2 audit tools to monitor the facility’s compliance with ensuring that each resident displaying wandering, sexually preoccupied behaviors, and/or displaying fondness for a peer have a plan of care in place to provide adequate supervision to safeguard them from sexual abuse and that all staff are aware of behaviors and actions to take in order to safeguard and supervise residents that may be at risk for sexual abuse. 2) Audits will be done by RNs weekly x 4 weeks on all residents that have these behaviors documented in the progress notes followed by monthly x 5 months. 3) Audits will be done by RNs weekly on 6 random nursing staff members weekly on safeguarding and monitoring residents to prevent sexual abuse followed by 6 random nursing staff members monthly x 5 months. 4) Findings from the audits that require corrective actions will immediately be rectified and brought to the Morning QA Meeting for review. 5) Findings will be reviewed during the Quarterly QA Meeting to ensure sustainability. IV. Person Responsible for this FTag: DNS