Failure to Protect Resident from Sexual Abuse
Penalty
Summary
Ridgeview Healthcare & Rehab Center was found to be non-compliant with federal and state regulations regarding the freedom of residents from abuse, neglect, and exploitation. The facility failed to protect a cognitively impaired resident, identified as Resident 2, from sexual abuse by another resident, identified as Resident 3. Resident 2, who suffers from Huntington's Disease and dementia, was unable to consent to or initiate sexual behavior due to severe cognitive impairment. Despite this, Resident 3, who is cognitively intact, engaged in inappropriate sexual conduct with Resident 2, which was witnessed by staff members. The incident occurred when two nurse aides, Employee 2 and Employee 3, entered Resident 2's room and observed Resident 3 performing oral sex on Resident 2. The aides immediately reported the incident to the registered nurse on duty, Employee 1. Resident 2 was found lying on her mattress with her incontinence brief removed, and when asked if someone had hurt her, she moaned "yes." A body audit revealed no physical signs of abuse, but the resident was sent to the hospital for a rape kit examination. The state police were notified, and an investigation was initiated. Interviews with the staff confirmed that Resident 2 could not have removed her brief or initiated the interaction due to her cognitive and physical limitations. Resident 3 admitted to the act but claimed that Resident 2 had initiated the interaction, which was not possible given her condition. Legal records indicate that Resident 3 is facing charges of indecent assault on a person with mental disabilities. The facility's failure to protect Resident 2 from abuse was confirmed by the Nursing Home Administrator during the survey.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. The facility will complete an assessment of current residents to identify residents that are at risk for engaging in or being victimized by sexual aggression. Residents that are identified as being at risk will have their individual care plans reviewed and updated with appropriate interventions. This assessment will be conducted upon admission, quarterly, after any significant change and post resident to resident aggression. 2. The facility will review and revise the current facility Abuse Prevention Policy to ensure compliance with federal and state regulations. 3. Facility will conduct re-education for staff across all departments and disciplines on: the facility abuse and prevention policy, recognizing, preventing and reporting sexual abuse. This re-education will include competency testing of staff. 4. Facility will conduct audits of residents to ensure a sexual aggression assessment has been conducted and appropriate interventions have been care planed. Audits will be conducted weekly x4, then monthly x 4. The facility will also conduct an audit of incidents. The purpose of this audit will be to identify any trends in recurring issues that need to be addressed through additional education and/or policy revisions. This audit will be conducted weekly x4, then monthly x 4. All results will be reported to the QAPI Committee.