Failure to Protect Residents from Sexual Abuse
Penalty
Summary
Corner View Nursing and Rehabilitation Center failed to protect a resident with severe cognitive impairment from unwanted and non-consensual sexual contact by another resident with a known history of sexually inappropriate behavior. The resident with the history of inappropriate behavior had previously engaged in unsolicited sexual contact with another resident, which was documented by the facility. Despite this history, the facility did not implement adequate supervision or interventions to prevent further incidents. The resident with the history of inappropriate behavior was admitted to the facility with diagnoses including dementia, mood disorder, and paranoid schizophrenia, and was assessed as moderately impaired. After the initial incident of inappropriate behavior, the facility updated the resident's care plan to include 15-minute checks, but these were discontinued the following day without developing further interventions to ensure the safety of other residents. This lack of continued supervision and intervention led to another incident where the resident was found in a compromising position with a severely cognitively impaired resident. The facility's failure to maintain adequate supervision and update care plans appropriately for residents with known behavioral issues resulted in an Immediate Jeopardy situation. The affected residents, both with severe cognitive impairments, were unable to protect themselves or consent to the interactions, highlighting the facility's responsibility to ensure their safety and well-being.
Plan Of Correction
Resident R1 was discharged to the hospital on 3/20/25 and will not return to the center. Resident R2 was assessed on 2/18/25 by nursing for any adverse effects of the alleged event and found no harm. Resident R2's responsible party and physician were contacted by nursing and sent to acute care hospital for in-depth evaluation on 2/18/25. R2 returned to the facility on 2/18/25 with no new orders and found to be at baseline. Psych consulted and assessed on 2/19/25 with no negative findings. R3 was assessed by nursing on 3/20/25 for any adverse effects of the alleged event and found no harm. R3's responsible party and physician were contacted and Resident sent to acute care hospital for in-depth evaluation by nursing on 3/20/25. Resident returned to the facility on 3/20/25 with no new orders and found to be at baseline. Psychosocial assessments performed by Social Services with no negative findings. Psychological services were consulted. House education done by 4/3/25, by DON/Designee provided to all staff reviewing identifying types of abuse, anonymous reporting, and reporting abuse. Megan law list check ran on all residents on 3/20/25, by DON/Designee. DON/Designee will audit all new admissions since 3/20/25, to ensure Megan law list checks were performed prior to admission. This was completed on 4/3/2025 by the DON. The DON/Designee was educated by the VP of Clinical Services on 4/2/25, on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk. The DON/Designee completed sexual activity scales on 4/2/25 on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed. No residents identified to be at high risk. The Directed In-Service will be presented to all staff by AAE Consulting Services for F600 Free from Abuse and Neglect on 5/1/25, with online video availability for any staff unable to attend the live sessions. Staff unable to attend will receive abuse education training prior to next scheduled shift. DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly x three months and as needed. The social services director/designee will interview 3 residents weekly x 4 weeks for abuse concerns. Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated on 4/2/25. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Removal Plan
- Resident R2 was assessed by nursing for any adverse effects of the alleged event and found no harm. Resident R2's responsible party and physician were contacted. Resident sent to acute care hospital for in-depth evaluation. Resident returned to facility with medication and found to be at baseline. Psych consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
- Resident R3 was assessed for any adverse effects of the alleged event and found no harm. Resident R3's responsible party and physician were contacted. Resident sent to acute care hospital for in-depth evaluation. Resident returned to facility with medication and found to be at baseline. Psychosocial assessments performed with negative findings. Psychological services were consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
- Root cause analysis identified that facility failed to provide adequate supervision to the alleged perpetrator.
- House education done by DON/Designee provided to all staff reviewing identifying type of abuse, anonymous reporting and reporting abuse.
- Megan law list check ran on all residents by DON/Designee. DON/Designee will audit all new admissions to ensure Megan law list checks were performed prior to admission.
- The DON/Designee was educated by the VP of Clinical Services on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk.
- The DON/Designee will perform sexual activity scale on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed.
- DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly times three months and as needed.
- Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated.
- Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.