Inadequate Supervision Leads to Sexual Abuse Among Residents
Penalty
Summary
The facility failed to ensure adequate supervision to prevent sexual abuse among residents, resulting in actual harm to three residents. On one occasion, a Licensed Practical Nurse (LPN) responded to a call for help in the dining room and found a resident touching another resident's genital area. The LPN removed the victim but left the aggressor unsupervised, who then proceeded to touch another resident inappropriately. The facility's investigation confirmed probable evidence of abuse, neglect, or mistreatment. Another incident involved the same aggressor entering a resident's room and touching them inappropriately. A Registered Nurse (RN) responded to the victim's cries for help and found the aggressor at the bedside with the victim's pants and sheets pulled down. The facility's investigation again concluded there was probable evidence of abuse, neglect, or mistreatment. Interviews with staff revealed that the aggressor had a history of sexually inappropriate behavior and was on 30-minute checks, but this supervision was insufficient to prevent further incidents. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving the same aggressor. The aggressor had a documented history of sexually inappropriate behavior and cognitive impairment, yet the interventions in place, such as periodic checks and redirection, failed to prevent further abuse. The facility's failure to adequately supervise and separate the aggressor from other residents led to multiple instances of sexual abuse, resulting in immediate jeopardy to the health and safety of the residents involved.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-600 I. The following actions were accomplished for the residents identified in the sample: **Resident #1** Resident #1 was hospitalized on [DATE] and remains in the hospital. If the resident is discharged back to the facility, the IDCPT will develop a care plan that addresses the resident’s risk of abusing other residents and to be abused with resident-specific care plan interventions. The facility has determined that the resident may require one-to-one supervision when he returns to the facility, but a determination will be made on his return. **Resident #2** The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/24/2024 following the resident-to-resident sexual abuse incident and no complaints were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident’s risk to be abused. On 3/26/2025 the IDCP Team completed an additional review of the resident’s risk to be abused care plan and updated it to include person-centered interventions based on the resident’s involvement with family and interest in recreational activities including: - Provide the resident with a cup of coffee and home magazines to flip through - Weekly rosary program - Utilize catholic prayers (Hail (NAME) and Our Father to calm the resident) - Music programs with emphasis on show tunes (favorite music) - Resident was removed from the early get up list, by preference (hx of combative behavior during caregiving) The resident has not been involved in any negative peer-to-peer interaction since 12/16/24. **Resident #3** The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/17/2024 following the resident-to-resident sexual abuse incident and no issues were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident’s risk to be abused. On 03/26/2025 the IDCP Team completed an additional review of the resident’s potential for abuse care plan and added additional person-centered interventions including: - Provide opportunities to watch old movies with her peers - Play music of preference i.e. Sinatra, Dean Martin, Perry Como - Participation in Busy Bees table to engage in diversional activity- ensure game is provided to the resident first, as per preference and history of grabbing items from others The resident has not been involved in any negative peer-to-peer interactions since 12/16/25. **Resident #4** The resident was seen by the social worker on 2/24/2025 and had no recollection of the incident that occurred on 2/22/2025. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 02/24/2025 following the resident-to-resident sexual abuse incident and no distress was identified at that time. The resident had been followed by psychiatry and psychology since readmission on 5/14/2024 related to her behaviors/ [DIAGNOSES REDACTED]. depression. She continues to be followed by both services and is closely monitored related to ongoing behaviors i.e. refusals of care, wandering, flirtatious comments, verbal outbursts. The resident is currently on 30-minute checks related to her behaviors. [MEDICAL CONDITION] medications inclusive of [MEDICATION NAME] sprinkles, duloxetine, [MEDICATION NAME] and trazodone continue to be part of the resident’s treatment plan. The IDCP Team updated the plan of care on 02/24/2024 to address the resident’s risk of being abused. On 03/26/2025 the IDCP Team completed an additional review of the resident’s risk of being abused. The care plan was updated to include: - If resident is upset and/or agitated call nephew or cousin to allow resident to speak with them - Offer activities of specific resident interest i.e. Good Housekeeping magazines, cards, casino games - Utilize soda and sweet snacks to divert from undesirable comments/behaviors (resident preference) - If resident refuses care, provide time and space and reapproach The resident has not been involved in any negative peer-to-peer interactions since 02/22/2025. On 03/05/2025, the facility developed and implemented a plan for Abuse Prevention education related to the immediate jeopardy situation to ensure all staff received this education prior to the start of their next assigned shift. 89% of staff on duty completed the education by 03/07/2025. This education continued through 03/25/2025. 100% compliance was met by all departments, other than nursing, which has a compliance rate of 96%. Directed In-service is scheduled to be initiated on 04/01/2025. II. The facility was notified of the immediate jeopardy situation on 03/05/2025 and implemented the following: The facility convened a QAPI meeting on 03/06/2025 to discuss the root cause of the abuse situation. Administration initiated staff training on the following topics on 03/06/2025: - Reporting process - How to report Abuse, Neglect and Mistreatment - Unit Behavior Management meeting - 1:1 observation and 30-minute monitoring - Role of the RN Supervisor regarding reporting abuse, neglect and mistreatment - Safeguarding residents with cognitive impairments against sexual and/or inappropriate behaviors III. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Please refer to corrective actions outlined at Sections II, III and IV of this DP(NAME). The CNO reviewed all Incident Reports for the period of 01/5 to 03/25/2025 and no additional events of abuse have occurred. The DNS/designee will continue to review all new Incident Reports daily to ensure prompt follow-up is completed for any type of abuse report. The facility’s QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 03/25/2025, to discuss the issues identified at F-600 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention principles and how non-adherence to abuse prevention practices, including management of resident sexual behaviors, can result in deficient practices such as those cited in the SOD. Education also addresses use of a Root Cause Analysis when compliance issues are identified. All resident care plans related to abuse risk, at risk to be a victim or to victimize, requiring behavior management or other interventions to prevent are being reviewed by the IDCPT and updated, as necessary, to address the resident’s current needs and problems and to ensure preventative measures are in place. If a care plan indicating potential risk to be a victim or to victimize has not been developed, one will be initiated for all identified at-risk residents. Nurse Managers will review the plan of care with the unit staff responsible and update the care plan and Kiosk as indicated. Effective 04/01/2025 through 04/03/2025, education will be provided by the outside consultant to all facility staff on the facility’s Abuse Prohibition protocols including behavior management principles for residents at risk to abuse and those at risk of being abused. The education will include types of abuse; need for identification and monitoring of resident behaviors that may result in a potential abuse situation for another resident and staff response to behavioral symptoms with appropriate interventions to prevent abuse from reoccurring. This education will continue to be provided until all facility staff receive this mandatory education. IV. The following system changes will be implemented to ensure continuing compliance with regulations: The CEO/Administrator, Medical Director and CNO and outside consultant reviewed and revised, as needed, the facility’s policy on Abuse Prohibition Protocols to ensure that it addressed monitoring of resident behaviors that may provoke a reaction by staff, residents or others or create potential situations of abuse and protocols to manage such behaviors. The policy was revised to include the utilization of unit-based behavioral management meetings to utilize in the identification and management of challenging and/or inappropriate behaviors. On 03/25/2025, the CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised, as needed, the facility’s policy on Resident Supervision Protocols. The policy was revised to include the use of 1:1 supervision and 30-minute checks to closely monitor a resident to ensure their safety and well-being, often due to behavioral, medical or cognitive concerns. On 03/25/2025 CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised the facility protocols for behavior management interventions related to managing a resident’s risk factors to abuse others or to be abused. This protocol includes identifying resident-specific risk factors to abuse or be abused and interventions to implement to prevent resident-to-resident abuse, including sexual abuse. Abuse Prevention education will continue to be provided by the Staff Educator/designee during orientation, annually and on an as-needed basis, including following any resident-reported abuse events. The Director of Social Work will follow up on all complaints voiced by a resident and/or family member regarding any allegation of abuse. The Director of Nursing and RN Supervisors will monitor for compliance during random and routine monitoring rounds and observations on the Nursing Units and medical record review. Immediate corrective actions, such as re-education or reevaluation of a resident’s plan of care regarding the potential to abuse or be abused, will be implemented as indicated. V. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by an outside consultant was convened on 03/25/2025 to examine this deficiency. The facility will develop an audit tool to monitor and evaluate staff knowledge and understanding of the facility Abuse Prohibition Protocol and responsibilities in monitoring of resident behaviors that may result in a potential situation of abuse if appropriate preventative actions are not implemented. The Staff Educator will audit twenty-five staff members for staff knowledge and understanding of Prevention of Abuse, Neglect and Mistreatment and Reporting Protocols monthly for the next six months and then on a quarterly basis for the next two quarters. The sample will include staff from all disciplines. Corrective actions such as reeducation will be implemented when indicated. The compliance for staff knowledge threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period, monthly auditing will continue as well as additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. Audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for evaluation and follow-up. The facility will develop an audit tool to monitor compliance with Abuse Prevention protocols to ensure documentation addressed resident-specific risk factors and interventions. DNS/designee will audit twenty-five resident care plans related to Abuse Risk and Behavior Management monthly for the next six months and then quarterly for the next two quarters. Residents who exhibit sexual behaviors will be included in the survey sample. Corrective actions such as reeducation and/or updating of the plan of care will be implemented when indicated. The compliance threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period, monthly auditing of at-risk for abuse or to be abused care plans will continue monthly with additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. All Abuse Risk and Behavior Management audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for evaluation and follow-up. The CNO/designee will continue to report all Abuse, Neglect and Mistreatment allegations and investigation findings to the QAPI Committee on an ongoing basis for evaluation, discussion and implementation of system changes to assist with the Prevention of Abuse, Neglect and Mistreatment. The CNO/designee will continue to review all reported allegations of abuse and make a report to the NYSDOH as per requirements. Responsibility: Chief Nursing Officer Completion Date: 4/17/2025