Failure to Implement Required Sexual Abuse Prevention Training and Monitoring
Penalty
Summary
The facility failed to implement its Plan of Correction (POC) as required to prevent and protect residents from resident-to-resident sexual abuse. The POC, which was signed and dated, specified that a third-party consulting agency would provide directed in-service training (DIST) to staff on the prevention and appropriate response to resident-to-resident sexual abuse. The POC also outlined that monitoring and monthly activities would begin within a specific timeframe. However, documentation and interviews revealed that the third-party training had not commenced by the POC completion date, and no staff had received the required training from the outside consultant. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that the third-party consultant had not started the abuse prevention training, and staff had not attended any such sessions. The DON acknowledged that the facility had only provided internal in-service training and that the third-party consultant had not delivered any training or monitoring as outlined in the POC. The DON also confirmed that none of the monitoring tools, clinical auditing, weekly on-site monitoring, or reporting to the state agency, as required by the POC, had been implemented. A review of facility policies indicated that staff training on abuse prevention, identification, and reporting is a required component of the facility's abuse prevention program. Despite this, the facility did not follow through with the specific actions and timelines detailed in the POC, resulting in a failure to provide staff with the necessary training and monitoring to prevent and respond to resident-to-resident sexual abuse.