Failure to Follow Abuse Policy During Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy when a nursing assistant (NA) observed a resident-to-resident sexual assault and left the room to seek assistance, rather than remaining with the resident to ensure their immediate safety. The incident involved two residents who were roommates, both of whom had significant cognitive impairments. During routine rounds, the NA discovered one resident touching the genitals of the other, who appeared to be sleeping and had removed his own undergarment. The NA attempted to verbally redirect the resident but was unsuccessful, prompting her to leave the room to find help from another staff member. Upon returning to the room with a medication aide (MA), the staff intervened and separated the residents. The MA then called a nurse for further assistance. Interviews with staff confirmed that the NA was aware of the facility's policy, which required staff to remain with the resident and ensure their safety during incidents of abuse, using available means such as the call light, calling out for help, or using a phone. Despite this training, the NA chose to leave the room, believing it would be faster to get help in person rather than using the call light. The facility's abuse policy, last revised in 2017, specifically states that all necessary steps must be taken to prevent further acts of abuse and that staff are to be trained and retrained regularly on these procedures. Multiple staff interviews, including those with supervisory and administrative personnel, confirmed that the NA's actions were inconsistent with facility policy and expectations. The incident directly affected one of the two residents reviewed for abuse and was substantiated through record review and staff interviews.