Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired male resident was not protected from sexual abuse by another cognitively impaired male resident. The incident took place in a shared room within the memory care unit, where a nurse aide overheard unusual laughter from one resident and, upon entering the room, observed one resident lying in bed with his penis exposed while the other resident was standing beside the bed, grasping and moving the exposed penis in an up and down motion. Both residents were severely cognitively impaired and lacked the capacity to consent to sexual activity. The nurse aide immediately intervened by instructing the resident to stop and separated the two individuals. Prior to the incident, neither resident had a documented history of sexually inappropriate behaviors. Both residents had care plans that addressed other behavioral symptoms such as wandering, disrobing in public, and physical or verbal behaviors, but there were no interventions or monitoring in place for sexually inappropriate conduct. The residents were both independent with eating, bed mobility, and transfers, but required staff assistance for other activities of daily living. One resident was being treated for a urinary tract infection and had been observed pulling at his groin area earlier that morning, but this behavior had not previously been associated with sexual activity. The facility's staff, including the nurse aide, nurse, unit manager, DON, and administrator, confirmed that neither resident had previously exhibited inappropriate sexual behaviors. The incident was witnessed directly by the nurse aide, and subsequent interviews with staff and responsible parties indicated that the event was unexpected and not anticipated based on the residents' prior behavior or care plans. The lack of identification and intervention for potential sexually inappropriate behaviors in the care planning process contributed to the failure to protect the resident from abuse.
Removal Plan
- Both residents were separated and placed on one-to-one supervision by facility staff.
- Staff that witnessed the event were interviewed by the Nurse Supervisor and statements were obtained.
- The Nurse Supervisor interviewed both residents regarding the occurrence.
- Resident #2 was moved to a different room.
- Responsible Parties for both residents were notified by the licensed nurse.
- The Medical Director and Nurse Practitioner were notified of the occurrence.
- The local Police Department was notified by the Nurse Supervisor.
- Licensed Nurse conducted skin assessments on both residents.
- An initial report was sent to the North Carolina Department of Health and Human Services.
- Adult Protective Services was notified of the allegation of resident abuse.
- Psychiatric services was notified for Resident #1; a telehealth and follow-up in-person visit were conducted.
- Medication changes were recommended and implemented for Resident #1 (increased Depakote, Hydroxyzine as needed).
- Resident #2’s Zoloft was increased to decrease libido.
- A chart review was completed for both residents by the Director of Nursing.
- Skin assessments were completed on all non-alert/oriented residents by licensed nursing staff.
- Social Worker Director and Assistant Social Worker interviewed all alert and oriented residents regarding resident abuse.
- Residents with roommates were interviewed to ensure roommate compatibility.
- Medical record audit of all residents was completed to identify residents with behaviors and review for sexual behaviors.
- Residents identified as having behaviors are reviewed in clinical morning meetings to ensure appropriate interventions are in place.
- Interventions for residents with behaviors include medication regimen review, one-to-one supervision, psychiatric consultation/visit, physician notification and assessment, and roommate compatibility.
- Education was provided to all facility staff (including agency staff) on the abuse policy with emphasis on sexual behaviors, management of symptoms, and ensuring resident safety by reporting, identifying, preventing, and managing behavioral symptoms.
- Any staff not receiving abuse education will not be allowed to work before receiving education.
- All newly hired staff, including new agency staff, will be educated on the facility's abuse prohibition policy in new hire orientation.
- The Director of Nursing and Nurse Practice Educator are tracking abuse education to ensure no staff works prior to receiving education.