Failure to Protect Resident from Sexual and Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual and physical abuse by another resident with a known history of sexually inappropriate, agitated, and hostile behaviors. The resident who was abused had diagnoses including schizoaffective disorder, bipolar disorder, Alzheimer's, and major depressive disorder, and was assessed as having moderate cognitive impairment. The perpetrating resident had diagnoses of anxiety disorder, mild intellectual disabilities, and was newly diagnosed with hypersexuality. This resident had a documented history of making sexually inappropriate statements, attempting to enter other residents' rooms, and displaying aggressive behaviors toward both staff and other residents. Despite the perpetrating resident's ongoing behavioral issues, including documented incidents of sexual aggression and physical violence, the facility did not implement adequate interventions or monitoring as outlined in their own policies and behavioral health recommendations. The care plan for the perpetrating resident identified inappropriate sexual behaviors and wandering, but interventions were limited to behavior monitoring without clear evidence of effective preventive strategies. Staff and leadership were aware of the resident's behaviors, including recent threats to staff, but failed to communicate these risks effectively or to update care plans and interventions accordingly. The incident occurred when the perpetrating resident entered the victim's room, physically assaulted her, and committed sexual abuse. The event was witnessed by an LPN, who intervened and separated the residents. The victim was assessed and sent to the hospital, where a sexual assault was confirmed. Law enforcement was notified, and the perpetrating resident was arrested. The facility's failure to implement and communicate appropriate interventions and to follow up on behavioral health recommendations directly contributed to the occurrence of this abuse.
Removal Plan
- R48 was assessed for injury, changes in behavior, trauma, and pain. NP gave orders to send R48 to the Hospital for evaluation and treatment. The patient was sent to the hospital for evaluation and treatment. MD and family were notified. R48 was discharged back to the center from the hospital. Center nurses began observation on the patient to ensure feelings of safety with no noted distress. Patient had a visit with behavioral health for a psychosocial support visit. Patient refused to see the behavioral health NP. Patient did have visit by hospice. Behavior health visit for the patient completed.
- R121 was immediately removed from R48 room by the LPN Charge Nurse and placed on one-on-one observation by a CNA until police arrived at the center to test the patient. Patient R121 was arrested.
- Skin audits were conducted on all residents to evaluate for any signs of abuse by the facility charge nurses and nurse managers. R48 noted with bruising to the thigh. No other adverse findings for other patients were audited.
- Resident with BIMs of 10 and above were interviewed by licensed nursing staff.
- In-service education was initiated for staff and to include abuse prohibition, abuse reporting, burnout, and de-escalation for all staff of the facility. Education was provided by the Administrator, Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director.
- A Resident Council Meeting was held. Abuse & Neglect Prevention to include Residents Rights reviewed by Activities Director. R48 was in attendance at the meeting.
- Interviews were completed on all residents who are interviewable to identify any concerns for abuse by the Social Services Director, Director of Nursing (DON), Activity Director (AD), and Nurse Managers. All denied any type of abuse or neglect.
- R48 was interviewed by the Administrator. Expressed no problems at this time and was happy and planning to attend activities.
- A Root Cause Analysis was completed for the Abuse Prevention. Root Cause identified that the center failed to implement interventions to protect the residents as outlined on the behavior health visit. A communication tool was developed to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events. Education of this process has been provided to the nurse leadership, SSD, and behavior provider by the DON.
- Education was provided to all cognitive residents regarding the Elder Justice Act and reporting of abuse by the Social Services Director and the Director of Social Services.
- Education provided to the center leadership team by the Governing Body on abuse prohibition policy to reviewing adverse events during Quality Assurance Performance Improvement (QAPI), recognizing trends to create proactive measures to reduce further reoccurrences, and utilization of non-pharmacological interventions as warranted for patients to promote safety of all patients.
- Re-education was completed for staff and to include abuse prohibition, abuse reporting to include physical and sexual aggression, burnout, and de de-escalation for all staff of the facility. Education was provided by the Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. All staff have been in serviced which totals 100%. No staff shall work until they have completed in-service education. Contract and newly hired associates will be educated upon hire on abuse prohibition, abuse reporting, burnout, and de-escalation by the Nurse Manager, DON, or ADON.
- Audits started by the social service director to interview residents to ensure they feel safe, and associates' interviews have been completed to ensure they know the process for reporting and can identify abuse, including sexual and physical aggression. Any noncompliance identified will be addressed by the Administrator assistant and/or [NAME] by written education, and incidents identified will be reported following the HFRD reporting protocol.
- The DON, Financial Controller, and Nurse Managers notified all current non-interviewable resident representatives via written notification on Abuse & Neglect Prevention Policy, and the Elder Justice Act and reporting.
- An ADHOC QAPI meeting was held with the Medical Director, center leadership, and Governing Body to notify of the deficiencies cited and the interventions implemented to ensure that the deficient practices do not reoccur. The Abuse Policy was reviewed with no needed revisions needed.