Sexual Abuse by Staff Member at LTC Facility
Penalty
Summary
Edenbrook of Greenwood Hill was found to be non-compliant with federal and state regulations following an incident involving sexual abuse of a resident by a facility staff member. The deficiency was identified during an abbreviated complaint survey, which revealed that a nurse aide, Employee 3, engaged in sexual acts with a resident, Resident 1, who was cognitively intact. The incident was witnessed by another staff member, Employee 1, who reported seeing Employee 3 receiving oral sex from Resident 1. This incident was not isolated, as further investigation revealed that Employee 3 had engaged in similar inappropriate conduct with Resident 1 over the course of a month. The facility's failure to prevent, identify, and respond appropriately to the sexual abuse placed Resident 1 and all other residents at risk for further harm. Despite having an abuse prevention policy in place, the facility did not detect the ongoing abuse, which was only brought to light when Employee 1 witnessed the act and reported it. Interviews with staff and the resident confirmed the occurrence of prior sexual encounters initiated by Employee 3, which went unnoticed by the facility's management. The deficiency was classified as Immediate Jeopardy due to the facility's inability to protect residents from abuse by staff members. The report highlights the facility's lack of effective monitoring and intervention, which allowed the abuse to continue undetected. The Immediate Jeopardy was identified on February 13, 2025, following the incident on February 9, 2025, when the sexual act was observed.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator, if possible safely, until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education will include that while alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. Directed in-servicing will be completed for licensed nurses to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. A random sampling of residents (BIMS 12 and above) interviews to determine if any abuse occurred and if appropriate steps were followed. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.
Removal Plan
- An internal investigation was immediately initiated.
- The employee who left the resident with the perpetrator was suspended.
- The accused perpetrator was removed from the facility.
- The nursing agency was notified of the alleged accusation towards their employee.
- The abuse policy will be reviewed and revised.
- The facility staff will be educated on the abuse policy and procedure, protecting resident safety which includes remaining with the resident, and guidelines on preserving an investigative scene. Further no staff will be permitted to work until this education has been completed.
- The facility immediately completed resident interviews with those residents with BIMS of 12 and above to determine if any other residents were affected.
- The facility assessed residents with BIMS under 12 for signs of abuse.
- The QAPI Committee will reconvene to review the root cause of the noncompliance.
- The NHA or designee will take a random sampling of residents and interview them to determine if any abuse has occurred and if appropriate steps were followed. Further, a random sampling of employee interviews will be completed to ensure they know how to identify and respond to abuse. These audits will occur daily until further direction.