Failure to Protect Residents from Sexual Abuse and Harassment
Penalty
Summary
The facility failed to protect multiple residents from abuse, including sexual abuse and harassment, resulting in actual harm. One resident with moderate cognitive impairment and a history of traumatic brain injury and dementia was found in another resident's room, lying on top of a non-verbal, fully dependent resident with her pants and incontinence brief pulled down. The assailant's penis was found near the victim's mouth, and he admitted to attempting vaginal intercourse. The victim was unable to consent due to her cognitive status and was sent to the hospital for a sexual assault nurse exam. The facility's records did not indicate any prior behavioral concerns for the assailant, and staff interviews revealed a lack of understanding regarding new safety measures, such as colored door tags for at-risk residents. Another resident with a history of sexually inappropriate behavior toward female staff repeatedly made sexual advances and comments to two female residents, both of whom had cognitive or communication impairments. Despite these incidents, the facility failed to implement or document effective, ongoing interventions to prevent further harassment. The care plans for the involved residents were not consistently updated to reflect the incidents or to include new interventions, and there was no documentation of reassessment before discontinuing safety checks. Staff were not consistently informed or educated about the behaviors to monitor or the interventions required for the resident with a history of sexual inappropriateness. The facility's investigations substantiated that abuse and harassment occurred, but staff interviews and record reviews showed gaps in communication, education, and implementation of protective measures. Staff were unaware of the purpose of new safety tools, such as door tags and education binders, and there was inconsistent documentation and follow-through on safety interventions like one-to-one supervision and frequent rounding. These failures resulted in continued incidents of sexual harassment and abuse, causing distress and harm to the affected residents.
Removal Plan
- The director of nursing (DON), the social services director (SSD), and designee interview/assess residents with BIMS assessment scores of eight or above for potential abuse.
- For residents with a BIMS score below eight, the power of attorney (POA) or residents' representatives are contacted to identify any concerns regarding abuse.
- Resident #8 is issued an immediate discharge notice to prevent further abusive behaviors.
- Resident #4 is placed on a one-to-one caregiver until alternate placement can be found.
- One-to-one caregivers are provided resident specific education defining what they are watching for (sexually inappropriate comments, monitoring for any inappropriate responses in sexual nature, with history of sexual assault allegations).
- One-to-one caregivers are educated on who to notify if any behaviors are identified/observed. The education is completed prior to the next scheduled shift.
- Nursing supervisors, the SSD and designee update Resident #4's behavior monitoring sheets to describe specific behaviors and staff response.
- Clinical resource reviews and updates Resident #4's Kardex, care plan and physician's orders.
- Resident #4 is evaluated by the primary care provider.
- Resident #4 receives psychology consultation orders, a medication adjustment to address sexual hyperactivity and a follow-up medication review is scheduled.
- Therapy sessions begin for Resident #4 to begin working with licensed mental health professionals.
- One-to-one supervision is in place for Resident #4. Updated education is initiated with all one-to-one caregivers.
- Education is provided to all staff on abuse, abuse prevention, behavior management, how to report new behaviors, how to locate information in the Kardex and care plan, and any one-to-one resident specific education prior to initiation of their next shift.
- All as needed (PRN) employees receive the education prior to the start of their next shift.
- Resident #4 is not seated near female resident(s) at activities or dining when at all possible.
- The interdisciplinary team (IDT) reviews and revises Resident #4's care plan to identify patterns in the resident's behaviors and implements interventions for Resident #4. The care plan revisions and interventions are communicated to front line staff caring for Resident #4. Interventions include Resident #4 is not to sit next to a female resident when at all possible.
- All residents with known behaviors are reviewed by the IDT team with updates as indicated to their care plans and Kardex.
- The facility updates the one-to-one education binder to detail residents' behavior pattern/risk; updates Resident #4's care plan; and, updates Resident #4's Kardex.
- The Abuse policies are reviewed/updated to include all sources of abuse, including resident-to-resident.
- The abuse investigation procedure and documentation process are reviewed and revised as needed. The NHA and the DON educate all staff on changes to the policies.
- The social SSD, the DON and the NHA re-educate all staff on facility abuse policies during the survey.
- In the event of any future resident-to-resident sexual abuse, the perpetrating resident is immediately placed on one-to-one supervision until the primary care physician, nursing, and psychology evaluations are completed. Outcomes of these evaluations result in continued one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. This is provided to the IDT team in the form of education.