Failure to Protect Residents from Sexual Abuse by Registered Nurse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving a registered nurse (RN). On one occasion, video footage captured the RN at the bedside of a resident with severe dementia, with his pants unzipped and his hand under the resident's blanket in the abdominal/pelvic area. There was no documented care need that would have required this action, and the resident was unable to communicate due to severe cognitive impairment. The incident was reported by the facility's administrator, and the evidence collected substantiated sexual abuse of a vulnerable resident. During the investigation of this incident, two additional residents reported inappropriate interactions with the same RN. One resident described an incident where the RN rubbed her back, moved his hands lower, and exposed himself, causing her significant distress and discomfort in participating in facility activities. Another resident reported that the RN applied cream to her neck without a physician's order and inappropriately touched her upper chest and nipples during the process. Both residents had some memory issues but were mostly alert and oriented, and neither had previously reported allegations of sexual abuse. A prior allegation involving the same RN was reported several months earlier, in which a resident alleged inappropriate physical touch. The facility investigated and reported the incident to authorities, but it was not substantiated at that time. The repeated nature of the allegations and the evidence from video footage demonstrate a failure by the facility to ensure residents were free from abuse, as required by federal regulations.