Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two residents reviewed for abuse and neglect. Specifically, the facility did not ensure a safe environment free from sexual abuse when a resident with a known history of inappropriate sexual behaviors placed her hand inside another resident's panties. The Director of Nursing (DON) did not implement necessary interventions upon the admission of the resident with a history of sexual behaviors, despite being informed by an LVN that the resident was masturbating and had inappropriately touched the DON during assessment. The facility's staff, including the DON, were unaware of the resident's history of inappropriate sexual behaviors prior to admission, even though documentation from the previous facility included multiple incidents of such behavior. The incident occurred when the resident with a history of sexual behaviors was found with her hand inside another resident's panties in the latter's room. Staff interviews revealed that the resident who was touched was supposed to be on 1:1 observation due to prior aggressive behavior, but there was a lapse in supervision during a shift change, and the assigned staff for 1:1 observation did not arrive on time. Other staff members were unaware of the need for close supervision of the resident with a history of sexual behaviors, and there was confusion and lack of communication regarding the assignment and implementation of 1:1 observation. The care plans for both residents did not initially address the risk of inappropriate sexual behavior or the need for specific interventions to prevent such incidents. Record reviews and staff interviews further indicated that the facility's admission process failed to identify and communicate the high-risk behaviors of the newly admitted resident. Key staff members, including the social worker, MDS coordinator, and admission coordinator, did not review or were unaware of the resident's documented history of inappropriate sexual conduct. The lack of proper review and communication led to insufficient care planning and supervision, resulting in the incident of sexual abuse between residents. The facility's policies on abuse, neglect, and supervision were not effectively implemented or followed at the time of the incident.