Failure to Protect Residents from Sexual Abuse and Inadequate Abuse Prevention Measures
Penalty
Summary
The facility failed to protect residents from sexual abuse and inappropriate touching, resulting in multiple incidents involving residents with severe cognitive impairment and dementia. Several residents with a history of sexually inappropriate behaviors were observed touching other residents inappropriately on multiple occasions. These incidents occurred despite the residents being known to have sexual dysfunction and behavioral issues, and despite previous interventions such as medication and 1:1 supervision. Documentation showed that after each incident, the involved residents were placed on 1:1 supervision, but the care plans were not always updated in a timely manner to reflect the current status or interventions. Staff interviews revealed inconsistent knowledge and implementation of abuse prevention protocols. Some CNAs and an LPN reported that their primary intervention was to redirect the resident and initiate 1:1 supervision, but they were not always aware of additional steps taken or required. There was also a lack of consistent and recent abuse education among staff, with some staff members stating they had not received abuse training in the weeks leading up to the incidents. The DON acknowledged that efforts to prevent recurrence included monitoring and attempting to keep residents separated, but there was no documentation that families were always notified of incidents involving their loved ones. Medical records and staff statements confirmed that the residents involved had severe cognitive impairment, with BIMS scores indicating significant deficits. The facility's own policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the incidents described met this definition. Despite the known risks and previous behaviors, the facility did not ensure adequate protection for all residents, as evidenced by repeated incidents of inappropriate sexual contact and insufficient updates to care plans and communication with families.
Removal Plan
- Identify total number of residents at risk for the same failed practice.
- Place affected residents on 1:1 supervision following incidents.
- Increase psychoactive medications for affected residents as ordered by the PA after incidents.
- Change resident’s room to reduce proximity to women.
- Send resident to the hospital for psychological evaluation after incident and maintain 1:1 supervision upon return.
- Maintain affected residents on 1:1 supervision after incident.
- Notify the PA of each incident and implement medication changes/interventions as directed.
- Interview all interviewable residents and assess non-interviewable residents for evidence of abuse or inappropriate/nonconsensual contact.
- Provide in-service training for all staff on abuse/neglect risk, sexual behaviors, identification of those at risk, protection measures, and dementia care, including documentation of 1:1 supervision.
- Require all current staff to complete in-service training before their next scheduled shift; no staff permitted to work until trained.
- Implement ongoing monitoring of resident behaviors to observe for potential to administer/receive abuse or neglect, including sexual abuse.
- Screen new admissions through interviews and record reviews for at-risk behaviors, including abuse/neglect and sexual behaviors.
- Care plan at-risk residents with individualized interventions, including possible 1:1 supervision and/or safe discharge, and document on baseline and regular care plans.
- Capture behaviors in behavior notes and screen daily by the DON or designee to identify behaviors that might lead to abuse/neglect, including sexual behaviors.
- Require staff to notify the DON or Administrator immediately of residents exhibiting increased sexuality or behaviors putting others at risk so immediate intervention can be placed.
- Add Psych Plus services to the facility’s service offerings.
- DON or designee to conduct daily review of all incidents and behavior notes to identify residents at risk for behaviors affecting others, including abuse/neglect and sexual behaviors.
- Continue staff training on dementia care, protective measures from abuse/neglect, behavior prevention/management, and documentation for 1:1 care, including for new hires.
- Administrator or designee to monitor abuse/neglect identification, protection from abuse/neglect, and dementia care, including behaviors that put self or others at risk.
- Daily review of allegations, incidents, and behaviors that put or potentially put self or others at risk, as well as documentation for 1:1 supervision.
- Carry information through the Quality Assurance Performance Improvement (QAPI) process.
- Ensure all residents that can be interviewed are interviewed and non-interviewable residents are assessed for evidence of abuse or inappropriate/nonconsensual contact.