Failure to Protect Residents from Repeated Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to immediately implement protective measures and conduct thorough investigations following 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 inappropriate sexual behaviors, including touching the breasts and legs of cognitively impaired female residents and masturbating in the presence of others. Despite these incidents, the facility did not consistently initiate or update interventions to prevent further abuse, nor did it always investigate or document the incidents as required. Key events included the male resident grabbing the breast of a female resident, rubbing the leg of another unidentified female resident, and attempting to touch another female resident's leg. In several cases, staff redirected the resident or moved the affected resident but did not implement new interventions or conduct investigations. The facility also failed to notify law enforcement after incidents of unwanted sexual contact, despite policy requirements and the inability of the affected residents to provide consent. Investigation reports were often incomplete or missing, lacking documentation of law enforcement notification and witness statements. Interviews with staff and administrative personnel revealed inconsistent understanding and application of abuse prevention protocols. Some staff were unaware of specific incidents or did not recognize the need for investigation and reporting. Administrative staff confirmed that law enforcement was not notified for any of the incidents and that some events were not fully investigated because they were not believed to be sexual in nature. The facility's actions and inactions placed cognitively impaired female residents at risk and resulted in a finding of immediate jeopardy.
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.