Failure to Prevent Sexual Abuse and Inadequate Supervision of Resident with Known Sexual Behaviors
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a serious incident involving two residents on the Special Care Unit. One resident with a history of severe cognitive impairment and Alzheimer's Disease was found in her bed with another resident on top of her, his hand inside her incontinence brief, performing jabbing motions. Staff observed scratches, bruising, and edema on the resident's labia and thigh, as well as bruising to her eyebrow. The incident was witnessed by multiple CNAs and a nurse, who reported that the male resident became violent and struck a staff member when they attempted to intervene. Prior to this event, the male resident had a documented history of sexually inappropriate behaviors, including making explicit comments, grabbing staff, and attempting to touch staff inappropriately. These behaviors had been ongoing since at least November of the previous year, with multiple entries in his medical record noting sexual comments and physical actions toward staff. Despite these documented behaviors, the facility did not implement effective interventions to prevent further sexual behaviors or protect other residents from potential harm. Staff interviews confirmed that the male resident frequently made sexual statements and gestures toward both staff and other residents, and had previously grabbed staff inappropriately. On the day of the incident, he was able to access another resident's room and commit sexual abuse, indicating a lack of adequate supervision and preventive measures. The facility did not assess other residents for signs of abuse immediately following the incident, and no body audits were performed on other residents at that time. The failure to address the ongoing sexually inappropriate behaviors and to implement sufficient interventions led to an incident that caused and was likely to cause serious harm.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified Resident #56's Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision.
- RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident # 56. No additional injuries identified.
- Primary physician notified of Resident # 16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident # 16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until in serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.