F0600

J

Failure to Protect Resident from Sexual Abuse by Staff Member

Akron, Ohio Survey Completed on 09-18-2025

Penalty

No penalty information released

Summary

A facility failed to protect a resident with moderate cognitive impairment from sexual abuse by a housekeeper. The housekeeper sent inappropriate text messages and photos to the resident, soliciting sexual favors, and subsequently engaged in sexual acts with the resident on two occasions. The resident reported performing these acts out of fear, and text message evidence corroborated the inappropriate communications initiated by the staff member. The resident's medical record indicated a history of traumatic brain injury, impaired cognition, and the presence of a legal guardian.

The facility did not recognize the staff-to-resident sexual contact as abuse, despite the resident's cognitive impairment and the power imbalance between staff and resident. Interviews with facility leadership and staff revealed a belief that the relationship was consensual, and the facility's abuse policy at the time did not explicitly prohibit staff-resident intimate relationships or address the issue of consent in cognitively impaired residents. The facility's investigation concluded that the resident had willingly participated, and there was no intent to cause harm, despite statements from the resident and her guardian indicating fear and lack of true consent.

The facility also failed to properly follow up with law enforcement regarding the incident. When the police were initially contacted, staff were unable to identify the perpetrator, and there was no subsequent update to the police once the staff member was identified. The facility did not implement additional interventions or follow-up in the resident's medical record after the incidents of sexual abuse were disclosed. The deficiency affected one resident out of three reviewed for abuse, in a facility with a census of 63.

Removal Plan

• Resident #50's friend updated facility staff that HK #208 came into Resident #50's room on two separate occasions in the previous week and made her perform oral sex on him.
• HK #208 was suspended pending further investigation.
• The facility opened a self-reported incident (SRI) tracking number 264268.
• HK #208's employment ended with the facility when the employee resigned.
• Resident #50 was signed up for psychological services with consent from her guardian and assistance from Social Services Designee (SSD) #212.
• Resident #50 was referred to follow-up with psychological services by Social Service Designee (SSD) #212 to evaluate mood status related to the incidents with HK #208.
• The social services designee completed a depression test, Patient Health Questionnaire-9 (PHQ-9), to evaluate the resident's mood status related to the incidents with the staff member.
• The President of Operations and President of Clinical Services educated the RDO #201 on BIMs assessment and scoring, staff to resident relations (as included in updated facility abuse policy deeming this act abuse), police follow-up, and thorough investigations.
• The President of Clinical Services updated the facility Abuse Policy to include staff to resident relations, specifically in the policy training section.
• The facility re-opened the SRI related to Resident #50. The police were updated that Resident #50 wanted to re-speak with them again.
• The RDO #201 and Regional Director of Clinical Services educated the Administrator and DON on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The Administrator and DON educated the following staff members: Activities Director, Human Resources Director, Unit Manager, Wound Nurse, Maintenance Director, Social Services Director, Central Supply Clerk and Housekeeping Supervisor on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the incident, the investigation, and the facility abuse policy not outlining physical and emotional contact between staff and resident.
• The facility completed a Brief Interview for Mental Status (BIMs) Assessment on all residents.
• All care plans were reviewed regarding cognitive status after the BIMS assessments were updated.
• The facility wound nurse completed skin assessments on all residents who had a BIMS of 12 or below.
• The facility Social Services Designee, Activity Director and the clinical management staff completed resident abuse questionnaires for residents with a BIMs score of 13 or above.
• All staff were educated on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The facility notified the police department regarding the abuse allegation, re-opening of the facility investigation for sexual abuse and provided the alleged perpetrator's information.
• The facility implemented a plan to complete head-to-toe assessments on five random residents who had a BIMs score of 12 or less to assess for signs and symptoms of abuse, five times a week for four weeks then five residents weekly for four weeks.
• The facility would interview five random residents five times for four weeks and then five random residents weekly for four weeks with abuse questionnaires for residents with a BIMs of 13 or higher.
• The facility would complete five random staff questionnaires on new abuse policy five times a week for four weeks and then five random staff weekly for four weeks.
• RDO #201 and the Regional Director of Clinical Services would audit facility SRIs for a thorough and proper investigation.
• RDO #201 and the Regional Director of Clinical Services would audit SRIs for police notification.
• All discrepancies would be submitted to the QAPI Committee and revised as needed for three months.