Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of sexual abuse and did not take adequate steps to prevent further potential abuse for two residents with severe cognitive impairment. Over a four-month period, a male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents and an unidentified female resident. Despite documented incidents where the male resident was observed touching female residents inappropriately, the facility did not consistently implement or update interventions to prevent recurrence, nor did they ensure that all staff were informed of the resident's behaviors and the necessary supervision measures. Record reviews and staff interviews revealed that the male resident had a documented history of sexually inappropriate behaviors, including touching female residents' breasts and inner thighs. Staff members reported that they were not always informed of the resident's history or the interventions required to prevent further incidents. In several cases, staff intervened only after witnessing inappropriate behavior, and there was a lack of evidence that care plans were updated or that supervision was consistently provided following each incident. Additionally, some incidents were not reported or investigated according to the facility's abuse prevention policy, and staff training on specific interventions for the resident was lacking. The affected female residents had severe cognitive impairment and were unable to advocate for themselves or recall the incidents. The facility's failure to thoroughly investigate all allegations, update care plans, and ensure staff were adequately trained and informed resulted in repeated incidents of sexual abuse. The lack of consistent supervision and failure to implement protective measures placed residents at risk of further abuse, mental anguish, and fearfulness.
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.
- 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).
- Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check 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, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.
- 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. 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.
- 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 will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately.
- DON/ Designee will review the 24-[NAME]