Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who had intact cognitive skills and the capacity to make decisions, reported that Resident 2 entered her room, unfastened her incontinent brief, and touched her private area. This incident occurred without the staff's knowledge, and Resident 1 felt scared and helpless. The facility's video surveillance confirmed that Resident 2, who had moderate cognitive impairment and lacked decision-making capacity, entered and exited Resident 1's room multiple times on the night of the incident. The staff's response to the incident was inadequate. When Resident 1 reported the abuse to RN 1, she was met with skepticism and was not believed. RN 1 did not take immediate action to investigate or report the incident. Similarly, when Resident 1 informed CNA 1 and LVN 1 about the incident, they also questioned the validity of her account, suggesting she might have been dreaming. The staff's failure to take Resident 1's report seriously and to act promptly contributed to the deficiency. The facility's policy on abuse prevention was not effectively implemented in this case. The policy stated that the facility does not condone any form of abuse and that the administrator is responsible for ensuring a safe environment. However, the staff's inaction and disbelief in Resident 1's report indicate a failure to adhere to these policies. The Director of Nurses was not present during the incident and only became aware of it after it was reported to her, highlighting a lack of immediate oversight and response to the situation.
Plan Of Correction
Free from Abuse and Neglect CFR(s): 483.12(a)(1) Corrective action: • On 3/17/25 Resident 1 was placed with a 1:1 sitter to make the resident feel secure and safe. • On 3/17/25 Resident 2 was on 1:1 staff to monitor his whereabouts. • Torrance Police were notified on 3/17/25. Officer Garcia spoke to Resident 2 to investigate the alleged sexual abuse. • Resident 1 was sent to Torrance Memorial Medical Center ER on 3/18/25 for further evaluation. Resident came back the same day with no unusual symptoms and trauma reported. • Resident 2 was sent to LADMC on 3/18/25 for evaluation and no longer resides in the Facility. • Resident 1 was seen and evaluated by the Psychiatrist on 3/19/25. Resident had verbalized to the psychiatrist that she is coping well and feels safe in the Facility. Resident 1 was monitored for anxiety. IDT was initially done on 3/18/25 with spouse. Follow-up IDT with Resident 1 and spouse on 3/21/25 regarding the outcome of the investigation, giving emphasis on Resident 2 being no longer in the facility. A copy of the video was sent to Torrance police for evidence, and additional interventions were done by the facility to prevent other residents from entering Resident 1’s room. Both Resident 1 and spouse had verbalized satisfaction and felt safe in the facility. How to identify potentially affected others: • On 3/25/25, all Department managers interviewed the Resident assigned to their ambassador rounds, asking if another resident, specifically describing the profile of Resident 2, entered their room. There was no other resident who entered their room. • SSD and DON interviewed all current residents from rooms 1-26 on 3/25/25, and there was no other resident affected by the same deficient practice. Based on the Department Managers' interviews as well as a preview of video surveillance, no other Resident was affected by this concern. Measures/Systemic change: • The Administrator gave in-service to 11-7 staff on 3/18/25 regarding Abuse reporting. • The Administrator gave in-service to all Department Managers on 3/18/25 regarding Abuse. • RN Supervisor 1 was given 1:1 in-service on 3/20/25 by DON regarding Abuse, giving emphasis on making sure that the alleged victim will feel safe and immediately providing another staff to stay with the resident. • The Administrator and DON gave 1:1 in-service to Supervisor 1 on 3/24/25 regarding Abuse, emphasizing on identifying alleged abuse and ensuring the resident's safety by assuring and keeping the victim safe. Disciplinary action was given to Supervisor 1. • The Administrator and DON gave 1:1 in-service to CNA 1 on 3/21/25 regarding abuse, emphasizing making sure that the victim of alleged abuse will not be left alone and that staff must immediately inform a supervisor. • DON gave in-service to Nursing staff on 3/18/25, 3/20/25, 3/21/25 regarding Abuse Prevention and Management, emphasizing the importance of making the victim feel safe and secure by having one staff with the resident. • Dietary Supervisor gave in-service to kitchen staff on 3/18/25 regarding Abuse. • Rehab Director gave in-service to Rehab staff on 3/21/25 regarding Abuse. Evening Hallway Monitoring was initiated on 3/22/23 from 9 PM to 7 AM. The RN Supervisor will assign staff to make rounds on the hallways to ensure that no resident attempts to enter other residents' rooms and to check any closed rooms. Nursing staff will document any findings every 30 minutes in the log between 9 PM and 7 AM. The scheduler will assign nursing staff 30 minutes of their time for rounds. The assigned staff will be designated in the sign-in sheets. Medical Records and/or Designee will audit the binder daily for charting and documentation for completion weekly. Findings will be discussed in daily clinical meetings for necessary action. QAPI was initiated on 4/5/25 regarding Abuse. Monitoring: • The DON will review the Evening Hall Monitoring Audit report for accuracy. Any negative trends will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completed on 4/10/25