Failure to Report Alleged Sexual Abuse of Multiple Residents
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, or theft for four residents. Despite state law and facility policy requiring immediate reporting of suspected abuse to appropriate authorities, including the state survey agency, local ombudsman, and law enforcement, the facility did not report multiple incidents of alleged sexual abuse involving a resident with a known history of sexually inappropriate behavior. Staff interviews and documentation revealed that the behaviors of this resident, which included touching, kissing, and other inappropriate contact with non-consenting residents, were widely known among staff and had been ongoing for months. Specific incidents included a resident's family reporting that their relative had been harassed and touched by the male resident on multiple occasions, with the facility failing to report this to the state survey agency. Staff members described witnessing the resident being sexually inappropriate with several other residents, including those who were cognitively impaired and unable to defend themselves. Despite these observations and verbal reports to facility administration, no formal reports were made to the required authorities as mandated by law and facility policy. Interviews with staff further confirmed that management was aware of the ongoing behaviors but did not take appropriate action to report the incidents. Some staff were told by administration that the behaviors were not inappropriate or were dismissed with comments minimizing the seriousness of the incidents. The failure to report these allegations resulted in a situation where residents, including those with severe cognitive impairments and limited ability to communicate, were left unprotected from further abuse.
Removal Plan
- Resident R1 was placed on 1:1 supervision and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.
- Residents R3, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1.
- Resident R1 and R2 were immediately separated.
- Resident R2 was assessed for injuries and no injuries noted.
- Resident R2 was sent to the hospital for further evaluation and remains at hospital.
- Current female residents who were cognitively intact were interviewed.
- Current female residents who were cognitively impaired had a skin assessment completed.
- Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Resident R1 will remain on 1:1.
- Resident R1 will be evaluated by psychiatry services in conjunction with the facility medical director.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively intact daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively impaired daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator.
- Affected residents will be seen by facility contracted psychiatry/psychology provider if they request to do so to address their emotional trauma.
- This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.