Failure to Notify Physician and Representative After Resident Sexual Abuse Incident
Penalty
Summary
Facility staff failed to immediately inform a resident, the resident's physician, and the designated representative following a significant change in the resident's condition involving an incident of sexual abuse. The incident involved a female resident with severe cognitive impairment and a history of senile degeneration of the brain, who was found by a CNA in the dining room with her bra around her waist and without a brief, while a male resident with moderate cognitive impairment and a history of brain compression and schizophrenia was present. The CNA observed the male resident massaging the female resident's breast over her blouse and holding her undergarments. The CNA reported the incident to an LVN, who then notified the Administrator and performed a skin assessment on the female resident, finding no injuries or distress at that time. Despite the incident, there was no documentation in the progress notes regarding the event, nor was there any notification to the physician or the designated representative of the female resident. The LVN stated she was instructed by the DON to wait for clarification from the Administrator before documenting the incident or notifying the physician and family. The Administrator later acknowledged that the nurse was supposed to notify medical staff, the designated representative, the DON, and Administration, but this did not occur due to improper education of the nurse. The DON was uncertain about who made the decision not to notify the designated representative, and the designated representative confirmed they had not been informed of the incident. The nurse practitioner (NP) for the residents was also not notified of the potential sexual abuse and only became aware of a significant event when informed that state surveyors were present in the facility. The facility's policy required licensed nurses to inform family or responsible parties of changes in condition and to document all nursing actions, physician contacts, and resident assessments in the nursing progress notes. These steps were not followed in this case, resulting in a failure to meet notification and documentation requirements after a significant change in a resident's condition.