Failure to Protect Residents from Sexual Abuse Due to Lack of Supervision and Communication
Penalty
Summary
The facility failed to protect residents from sexual abuse by not implementing immediate supervision or restrictions for a male resident with a known history of sexually inappropriate behaviors. Despite prior incidents of sexual comments and inappropriate conduct toward staff, no care plan interventions or increased supervision were put in place before the resident inappropriately touched two female residents in the day room. The first incident occurred when the male resident touched the breast of a female resident, which was witnessed by a janitor who separated the residents and notified an LPN. After the initial incident, the LPN escorted the male resident to his room but left him unsupervised while reporting the event to the DON. During this time, another CNA, unaware of the incident, assisted the male resident back to the day room, where he subsequently inappropriately touched the breast of a second female resident. Staff interviews confirmed that there was a lack of communication regarding the initial incident, and the male resident was not placed on one-to-one supervision until after the second incident occurred. The male resident involved had a history of cognitive impairment, poor judgment, and previous sexually inappropriate verbal behaviors, as documented in his medical and psychiatric records. Both female residents who were touched also had severe cognitive impairments. The facility's failure to implement protective supervision and communicate the risk to all staff resulted in two residents experiencing non-consensual sexual contact and placed other vulnerable residents at risk.
Removal Plan
- Hold QA meeting to review Abuse Policy and Care plan policies with all disciplines.
- Start 1-1 observation by DON and ADON when an incident is reported. Assign this to the scheduled Certified Nursing Assistant (CNA).
- Conduct in-services on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. Train all staff that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. Do not allow staff to work until in-serviced.
- Discipline and educate LPN #1 on 1-1 supervision when there is an abuse allegation.
- Educate CNA #1 on proper undergarment placement for Resident #2.
- Update Care Plans for all Residents involved and review all residents with behaviors and their care plans.
- Conduct body audits on Resident #2 and Resident #3.
- Initiate hourly checks on Resident #2 and Resident #3.
- Send referrals to multiple Geri-psych units and other facilities for Resident #1.
- Assign 1-1 observation of Resident #1 to the scheduled Certified Nursing Assistant (CNA). Use Post Event Hourly Monitoring Form.
- Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.