Failure to Prevent Sexual Abuse and Inadequate Supervision of Resident with Known Sexual Behaviors
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 [email protected].
- 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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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