Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect three residents from sexual abuse by a certified nursing assistant (CNA). Each of the three residents, all of whom were cognitively intact and able to communicate, reported separate incidents in which CNA 4 inappropriately touched them during personal care. One resident described the CNA fondling her clitoris and inserting his fingers into her vagina during a brief change, which she reported to both her husband and the facility. Another resident stated that the CNA massaged her vagina, both externally and internally, under the pretense of helping her sleep, and she later expressed regret for not reporting the sexual nature of the abuse sooner. The third resident reported that the CNA inserted his finger into her vagina after a brief change and noted that the inappropriate touching only occurred when the CNA was alone with her. The facility's hiring process for CNA 4 was deficient, as his personnel file contained two negative reference checks from previous employers, both indicating poor performance and stating they would not rehire him. Despite this, the facility's investigative summaries inaccurately reflected only positive references. The director of nursing (DON) and administrator (ADM) stated they had not seen the negative references prior to hiring and would have hesitated to hire CNA 4 had they been aware of them. The facility did not have a policy regarding reference checks, and the responsibility for checking references was left to human resources, resulting in a lack of oversight. Additionally, the facility did not provide abuse-related in-service training to CNA 4 after the first report of sexual abuse, as he was suspended and subsequently resigned. The facility's policy stated that all employees would be properly screened prior to employment and that staff would be trained to identify and report abuse, but these procedures were not effectively implemented. The residents involved experienced psychosocial harm, including feelings of humiliation, anger, anxiety, and worry, as a direct result of the abuse and the facility's failure to prevent it.