Failure to Provide Timely Post-Assault Care and ER Transfer
Penalty
Summary
The facility failed to act in a timely manner and ensure that a resident received necessary care and services following a substantiated incident of sexual assault. The incident involved a resident in a persistent vegetative state, fully dependent on staff for all care, who was observed by a staff member to be the victim of an unwanted sexual act performed by a roommate. Facility policy and CDC guidelines require immediate medical evaluation and evidence preservation in such cases, including prompt transfer to the emergency room (ER) for examination and possible collection of forensic evidence. Despite these requirements, the facility did not offer or arrange for the resident to be transferred to the ER immediately after the incident. Documentation and interviews revealed that the responsible party was not offered the option to transfer the resident to the ER until two days after the event, at which point the offer was declined. Staff interviews confirmed that the on-call provider was notified but only advised monitoring the resident, and that the responsible party was not informed of the option for ER evaluation at the time of the incident. Further, the on-call provider and physician assistant were not given full details of the incident, which limited their ability to make appropriate clinical recommendations. The facility's Director of Nursing and Executive Director both stated that the expected protocol would have been to send the victim to the ER immediately to preserve evidence and provide appropriate care, but this did not occur. The failure to follow established protocols resulted in a delay in care and services for the resident following the sexual assault.