Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, specifically sexual abuse, among residents. Over a four-month period, a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors inappropriately touched at least two female residents, both of whom also had severe cognitive impairment and were unable to advocate for themselves. Despite documented incidents of inappropriate touching, including fondling of breasts and inner thighs, the facility did not consistently update care plans, provide adequate supervision, or ensure staff were informed of the resident's behaviors and necessary interventions. Staff members, including LVNs and CNAs, were not consistently aware of the male resident's history of sexual behaviors or the interventions required to prevent further incidents. Several staff interviews revealed a lack of specific training or in-service education regarding the resident's behaviors and the facility's abuse prevention protocols. In some cases, staff did not immediately report incidents of abuse to the Administrator as required by policy, and there was confusion about the appropriate steps to take following such incidents. The care plans for the involved residents were not always updated promptly to reflect new risks or interventions after incidents occurred. The facility's failure to separate residents after incidents, provide 1:1 supervision when indicated, and ensure all staff were aware of and trained on abuse prevention measures contributed to repeated occurrences of sexual abuse. The male resident continued to have access to vulnerable female residents, and interventions such as increased supervision or room changes were inconsistently applied. These failures placed residents at risk of further abuse, mental anguish, and fearfulness, as documented by surveyor observations, interviews, and record reviews.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource, including how to conduct a thorough investigation to implement measures to prevent further incidents and protect other residents.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by RN, Clinical Resource. Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan.
- This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.
- DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s)) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed and no additional discrepancies were identified.
- Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.
- Safe-Surveys were conducted by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to report.