Failure to Immediately Report and Respond to Resident-to-Resident Sexual Incident
Penalty
Summary
A deficiency occurred when a staff member failed to immediately report an observed incident involving two residents engaged in sexual activity. The staff member entered the room, witnessed the event, completed her task of collecting hangers, and then left the room without reporting the incident. She subsequently went on her lunch break for approximately 30 minutes before informing a co-worker, who then reported the incident to the appropriate supervisory staff. This delay in reporting was contrary to the facility's policy, which requires prompt reporting of any witnessed abuse or neglect to the charge nurse. Both residents involved had documented cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores. The medical records and care plans showed that one resident had a history of seeking sexual intimacy and related behaviors, while the other also had cognitive limitations. The staff and supervisory interviews revealed uncertainty among staff regarding the residents' capacity to consent to sexual activity, especially given their BIMS scores. Despite the facility's policy allowing sexual intimacy between consenting adults deemed capable by MDS guidelines, staff were unclear about the application of these guidelines in this situation. The failure to immediately report the incident and ensure the safety of both residents, as well as all other residents in the facility, constituted a breach of the facility's abuse/neglect policy. The delay in reporting and lack of immediate intervention placed all residents at risk, as the staff did not promptly assess or secure the safety of those involved or others who might be affected. The deficiency was identified through interviews, medical record reviews, and examination of facility documentation, confirming that the required procedures were not followed.
Plan Of Correction
F 600 Tag F0600 438.12 Free from Abuse, Neglect and Exploitation 1. Corrective Action – On [R] Resident#1 and Resident #2 were [R] and placed on [R] by nursing. – On [R] Resident #1 and Resident #2 were transferred to the local hospital for evaluation. – On [R] the incident was reported to local [R]. – On [R] upon return from the hospital, Resident #1 and Resident #2 were placed on [R]. – On [R] the US FOIA (b)(6) received education from the HR Director on [R] and [R] and timely reporting. – Or [R] the US FOIA (b)(6) received a final discipline from HR Director for lack of timely reporting of the event to the appropriate staff. – On NJ Exec Order 26, the facility orientation for new employees was revised by the HR Director to include education on and NJ Exec Order 26.4 NJ Exec Order 26.4b1 and timely reporting. – Or NJ Exec Order 26.4D, the employee annual orientation requirements have been revised by the HR Director to include sexual abuse, timely reporting, and resident's ability to consent to sexual activity. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: – All residents have potential to be affected by the deficient practice. 3. Measures Put in Place: – The DON/designee will conduct facility education for all staff and assess all staff competency related to abuse and neglect, timely reporting, and facility sexual intimacy policy monthly for 6 months. – The HR and/or designee will randomly audit monthly, for 6 months, 10 employees' comprehension of facility abuse and neglect policy and timely reporting. 4. How Will These Actions Be Measured: – The results of the monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated facility staff on the facility's policy on NJ Exec Order 26.4b1
- Educated staff on the ability for residents to consent to NJ Exec Order 26.4b1 with each other
- Educated staff to report any incidents between residents and ensure the NJ Exec Order 2 residents were safe
- Conducted audits to monitor compliance with education
- Conducted staff assessment and testing to ensure staff had a true understanding of education