Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R29, was free from sexual abuse, resulting in the resident contracting a sexually transmitted infection (STI). The deficiency was identified through a review of facility policy, clinical records, observations, and interviews with residents and staff. Resident R29, who was admitted to the facility with severe cognitive impairment and a court-appointed guardian, was found to be in a relationship with another resident, Resident R67. Despite the known cognitive limitations of Resident R29, the facility did not have a care plan addressing her sexual behaviors or the relationship with Resident R67. Resident R29 was diagnosed with Trichomoniasis, a sexually transmitted infection, after a gynecological exam. The facility's records did not show any follow-up by social services, medical services, or management to assess the relationship between Resident R29 and Resident R67 or to revise her care plan to address her sexual behavior. Interviews revealed that staff were aware of the relationship and had reported it to management, but no interventions were implemented to manage the situation or prevent further incidents. The facility's failure to supervise and implement necessary interventions for Resident R29, who has severe cognitive impairment, allowed her to enter a relationship with Resident R67, who is cognitively intact. This lack of action resulted in harm to Resident R29, as evidenced by the STI diagnosis. The facility did not develop or implement interventions after the suspected sexual abuse occurred, nor did it prevent further incidents, leading to a deficiency in ensuring the resident's right to be free from abuse and neglect.
Plan Of Correction
1. R29, R67 charts have been reviewed and updated to reflect current status. R67 and R29 are currently followed by psych services. R29 gynecological follow up is 3/5/2025. Guardian has been updated. R29 and R67 visitations will only be allowed in common areas. 2. House review has been completed to ensure no other residents identified. 3. All Facility staff will be in-serviced via directed in-service LW Consulting on 2/27/25 for F600 freedom from abuse/neglect with focus on sexual abuse. 4. Director of Nursing/designee will educate all staff on facilities policy and procedure of abuse/neglect. 5. Director of Nursing/designee will monitor 24-hour report, progress notes for any instances that fall into this category at clinical meeting. 6. Director of Nursing/designee will audit weekly x2, monthly x2 progress notes and 24-hour report. 7. Results of in-service, monitoring and audits will be submitted to the Quality Assurance Performance Improvement Committee.