Failure to Protect Resident from Sexual Abuse by Another Resident with Known History of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a documented history of inappropriate sexual behavior, including walking around the facility with his genitals exposed and masturbating excessively. Despite multiple documented incidents of this behavior, the facility did not implement effective interventions or closely monitor the resident exhibiting these behaviors. The care plan for the resident with inappropriate sexual behavior included a general intervention to protect the rights and safety of others, but this was not adequately followed or enforced. The resident who was abused was nonverbal, severely cognitively impaired, and completely dependent on staff for all activities of daily living, including mobility and personal care. On the night of the incident, a CNA heard noises from the resident's room and discovered the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate about the incident, and staff observed the other resident pulling up his pants and leaving the room. The facility called emergency services, and the nonverbal resident was transferred to a hospital for evaluation of sexual assault. Interviews and record reviews revealed that the facility was aware of the sexually inappropriate behaviors prior to the incident, as documented in progress notes, care plans, and medication records. However, the facility did not conduct an interdisciplinary team meeting to address the ongoing behaviors or develop more effective interventions. Staff, including the DON and Social Services Director, acknowledged that the care plan was not followed and that closer monitoring and team intervention should have occurred to prevent the incident.
Removal Plan
- The facility staff separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision.
- The facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation.
- The facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior.
- The facility readmitted Resident 2 from GACH3 and provided one-to-one supervision.
- The facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric hold) due to inappropriate sexual behavior.
- The Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff.
- The facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2.
- The licensed nurses checked seven nonverbal residents for any signs of skin discoloration to the genital areas.