Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report multiple incidents of resident-to-resident abuse involving a male resident with severe cognitive impairment and a history of high-risk sexual behavior. This resident repeatedly engaged in sexually inappropriate behaviors, including touching and grabbing the breasts and legs of cognitively impaired female residents, masturbating in the presence of others, and making sexually explicit comments. Despite these incidents being observed and documented by staff, the facility did not notify the Licensed Nursing Home Administrator (LNHA), State Agency (SA), or Law Enforcement (LE) as required by policy and regulation. The male resident's electronic health record documented diagnoses of altered mental status, psychotic disorder, high-risk sexual behavior, and Alzheimer's disease, with a severely impaired cognition score. The care plan identified risks for sexually inappropriate behaviors and included interventions such as one-on-one monitoring and medication for sexual aggression. However, after the resident returned from an acute behavioral facility, the only intervention implemented was medication, and no additional measures were taken to prevent further abuse. Staff continued to observe and document incidents of inappropriate sexual contact and behavior, but these were not consistently investigated or reported to the appropriate authorities. Interviews with staff and administrative personnel revealed a lack of consistent understanding and execution of reporting requirements. Some staff believed that law enforcement should only be notified if harm occurred or if requested by a resident's family, while others acknowledged that any unwanted sexual contact should be reported. Investigation reports for several incidents were incomplete or missing, and there was no documentation that law enforcement was notified for any of the incidents. This failure to report and investigate placed cognitively impaired female residents at risk and constituted a deficiency in the facility's abuse prevention and reporting practices.
Removal Plan
- The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured.
- The facility notified Law Enforcement.
- LN I received disciplinary action for failure to report the incident.
- LN F received disciplinary action for failure to report the incident.
- The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being.
- The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals.
- The facility immediately educated all staff regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations.
- The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation.
- The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone.