Failure to Protect Residents from Sexual Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an incident where one resident inappropriately raised another resident's shirt and grabbed their breast in a public area. Prior to this event, there were documented behavioral issues involving the same resident, including making other residents uncomfortable, using vulgar language, and inappropriate physical contact such as kissing another resident. Despite these documented behaviors, the care plan for the resident exhibiting inappropriate sexual behaviors did not include sufficient interventions beyond medication management, and there was a lack of comprehensive measures to prevent further incidents. Multiple residents with cognitive impairments and communication deficits were involved or affected by the inappropriate behaviors. One resident had diagnoses including bipolar disorder, Alzheimer's, and moderate cognitive impairment, while the resident who committed the abuse had severe cognitive impairment and a history of inappropriate sexual behaviors. Other residents reported feeling violated or uncomfortable due to the actions of the same resident, and there were staff observations of ongoing inappropriate comments and behaviors directed at both residents and staff. The facility did not conduct timely or thorough investigations into reported incidents of sexual abuse. For example, after a reported incident of inappropriate touching, the administrator acknowledged that no investigation had been conducted. Additionally, staff interviews revealed that safe surveys regarding abuse were not completed, and there was a lack of documentation and follow-up on previous incidents. These failures contributed to an environment where residents were not adequately protected from abuse, neglect, and exploitation.
Removal Plan
- General Manager completed the Process for Completion of a State Reportable.
- Administrator completed training on Abuse and Neglect and on Conducting an Abuse Investigation.
- In-service provided to Administrator and Corporate Nurse on Abuse investigation, Reporting, Completion, Conducting and the updated abuse policy.
- All staff educated on abuse, neglect, and exploitation by Administrator.
- Resident #2 educated on abuse and resident's rights.
- All staff educated on the reporting structure and provided contact information for the administrator of record.
- Resident #2 placed on one-on-one monitoring with direct care staff or designee when out of resident's room.
- Resident #2 medications to be reviewed by Psych NP and MD to assist with potential reduction and behaviors due to side effects if applicable.
- All findings and audits to be reviewed by Director of Nursing, Administrator and/or designees.
- Review of residents to list any residents at risk for inappropriate unwanted behavior, list to be done by Director of Nursing.
- All at risk residents will not be placed near Resident #2.
- All at risk residents will be care planned with interventions of maintaining placement when out of room away from Resident #2.
- All at risk residents who are at risk for unwanted behavior will be added to the shift monitor report so that the charge nurse and staff are aware to maintain distance from Resident #2.
- Facility will work with active family member to restructure visit times to be scheduled during high aggressive times once identified.
- Resident #1 will be monitored by the charge nurse for any psychosocial alterations.
- All staff and current residents interviewed to rule out abuse, neglect or exploitation using a safe survey.
- Abuse, neglect and exploitation policy updated to include specific verbiage on inappropriate sexual behaviors in the screening, training, prevention, and identification components.
- A QA was created and implemented pertaining to the inappropriate behaviors of Resident #2 with interventions.
- A monitoring form for interventions for Resident #2 was created and implemented.
- Education provided to activities/social services staff to do 1:1 activities with Resident #2 after lunch.
- Care plan for Resident #2 updated to include the interventions put into place.
- Care plan for Resident #1 updated to include the psychosocial monitoring and an order placed in the EMAR to be monitored by nurses.
- Resident #2's medication reviewed and Prevera dosage increased.
- Non-verbal/incapacitated residents interviewed using observation for facial expressions, gestures, and emotional cues/reactions.
- All staff instructed via electronic in-service to keep Resident #2 away from all residents identified as vulnerable or at risk of inappropriate behavior.
- When Resident #2 is out of room, staff instructed to move Resident #2 away from all identified at-risk residents in public areas, assigned to all staff and documented on daily monitoring form by charge nurse.
- Exception documentation if behavior occurs in the nursing notes and behavior record, to be completed by charge nurses.
- In-service documentation showed clinical staff attended in-person and via telephone training by the administrator over the facility's abuse policy.
- Resident #2's care plans updated to show 1:1 intervention and medication dosage increased to reduce behaviors.
- Resident #2 observed to ensure 1:1 intervention by clinical staff.
- Residents #1, #4, and #5 observed to ensure they maintained a safe distance from Resident #2.
- A list for residents with unwanted behaviors posted at the nurse's station.
- QA documentation showed the facility had a meeting where they addressed the abuse incident.
- General manager documentation for in-service completion for state reportable training reviewed.