Failure to Supervise Resident with Sexually Inappropriate Behaviors Creates Immediate Jeopardy
Penalty
Summary
The facility failed to provide necessary supervision for a resident with a known history of sexually inappropriate behaviors, resulting in an immediate jeopardy situation for multiple residents. The resident in question had severe cognitive impairment, a history of sexual offenses, and was identified as a registered sexual offender. Despite these known risks, the care plan interventions designed to monitor and manage the resident's behaviors were not implemented or documented as completed. Staff interviews and clinical record reviews revealed that the resident frequently wandered into other residents' rooms, engaged in inappropriate touching, and was not consistently monitored as required by the care plan. Multiple incidents were reported where the resident was observed engaging in sexually inappropriate behaviors with other residents, many of whom were cognitively impaired or physically unable to defend themselves. Staff and resident interviews indicated that these behaviors were ongoing and widely known among staff, yet there was a lack of formal reporting and documentation. Staff described instances of the resident touching, kissing, and following female residents, with some staff expressing discomfort and concern over the lack of action taken by facility management. In several cases, staff reported being discouraged from filing incident reports or were told by management that such behaviors were permissible among older adults. The facility's failure to follow its own policies for behavior management and resident supervision, as well as the lack of consistent documentation and reporting, allowed the resident's inappropriate behaviors to continue unchecked. This resulted in direct harm and distress to at least five residents, including incidents where residents were found in vulnerable positions and unable to recall or defend against the inappropriate actions. The deficiency was further compounded by the lack of timely intervention, inadequate monitoring, and insufficient staff education on handling residents with sexually aggressive behaviors.
Removal Plan
- Resident R1 is placed on 1:1 supervision and continues to remain on 1:1 supervision.
- Resident R1 care plan will be updated to individualized interventions regarding supervision based on his sex offender status.
- Resident R1 behavior is monitored by the 1:1 supervisor.
- Facility will identify and address any allegations of inappropriate touching/behaviors via facility policy and investigative process.
- Follow-up and follow-through of interventions will be monitored by the Director of Nursing and Nursing Home Administrator.
- Any affected residents identified, reporting will be completed, notifications will be made, and support will be offered to residents and family.
- Staff and consultants' failure to report any allegations timely will be addressed through the disciplinary process up to and including termination of employment or contracted services.
- An audit on all female residents will be completed by the Director of Nursing, or designee, to identify any documented inappropriate touching or sexually inappropriate behaviors.
- If any are found, facility policy and protocol of investigation, notification, and reporting will be followed.
- Current female residents who are cognitively intact are being interviewed five days per week.
- Current female residents who are cognitively impaired are having a complete skin assessment five days per week.
- With resident remaining on 1:1 supervision, female residents are being kept safe from Resident R1 inappropriate touching/sexual behaviors.
- Education was completed with all staff on Abuse/Neglect, Reporting of Incident and Accidents, and providing direct supervision with Resident R1 by the Director of Nursing.
- Education of all new hires will include supervision of handling residents with history of sexual aggression and behaviors. This will be updated into the new hire packet.
- Mandatory education will be sent to all staff to inform staff of updates to Resident R1 care plan interventions to successfully redirect sexual aggression and behaviors.
- Resident R1 will remain on 1:1.
- Resident R1 is being followed by facility contracted psychiatric provider in conjunction with the facility medical director.
- Referrals are being made to alternate care facilities that can better meet Resident R1's needs.
- 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.
- 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 or designee to address supervision of handling residents with sexual aggression and behaviors, including adding of this education to new hire orientation.
- This plan of correction will be monitored through facility Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.