Failure to Immediately Report and Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff implemented the abuse policy by immediately reporting allegations of abuse to the abuse coordinator for four residents who were reviewed for abuse. Multiple staff members, including RNs, LPNs, and CNAs, observed or were made aware of incidents involving sexual contact or interactions between cognitively impaired residents, but did not report these incidents to the abuse coordinator as required by facility policy. In several cases, staff were unsure if the residents involved had the capacity to consent or if their guardians had provided consent for sexual relationships, yet no immediate reporting or investigation was initiated. Specifically, one RN observed a resident groping another resident's chest in a lounge area but did not document or report the incident, stating she was unaware of the need to report it to the abuse coordinator. Another LPN witnessed similar behavior and also failed to report, believing that documentation in nursing notes was sufficient. In another incident, a CNA found two residents engaged in a sexual act, reported it to the unit manager, and the DON was notified, but the abuse coordinator was not informed, and no follow-up investigation was conducted. The DON confirmed awareness of the incident but did not report it, rationalizing that the residents had a longstanding relationship. All residents involved were documented as severely or moderately cognitively impaired and had full guardianship in place, indicating a lack of capacity to independently consent to sexual activity. The facility's abuse prohibition policy clearly requires immediate reporting and investigation of all allegations of abuse, including resident-to-resident sexual contact, especially when capacity to consent is in question. Despite this, staff failed to follow policy, resulting in unreported incidents and a lack of appropriate investigation or intervention.
Plan Of Correction
F0607 Develop/Implement Abuse/Neglect Policies Resident #103 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #106 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is responsible for sustained compliance.