Failure to Prevent and Address Sexual Abuse Due to Inadequate Monitoring and Lack of Interdisciplinary Intervention
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent sexual abuse, specifically by not closely monitoring a resident with a known history of inappropriate sexual behavior. This resident had documented behaviors of walking around the facility with his genitals exposed and masturbating excessively, as noted in multiple progress notes, care plans, and medication administration records. Despite these repeated incidents, the facility did not provide adequate supervision or interventions to prevent further inappropriate behavior. Another resident, who was nonverbal, severely cognitively impaired, and fully dependent on staff for all activities of daily living, was subjected to sexual abuse by the resident with the history of inappropriate sexual behavior. The incident was witnessed by a CNA, who observed the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate or verbalize the incident, and the event was confirmed by staff observations and subsequent medical evaluation. The facility also failed to conduct an interdisciplinary team (IDT) meeting to address the ongoing inappropriate sexual behaviors of the resident with a known history of such actions. Staff interviews and record reviews confirmed that no IDT was held to develop or implement effective interventions, despite clear documentation of repeated incidents. The lack of close monitoring and failure to convene an IDT contributed to the occurrence of sexual abuse within the facility.
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.