Failure to Protect Resident From Sexual Assault by Another Resident
Penalty
Summary
Administration failed to ensure that a resident was protected from sexual assault and maintained in an environment free from abuse, as required by the facility’s Resident Rights policy and the performance standards for the Nursing Home Administrator and Director of Nursing. The resident (R1) had diagnoses including Alzheimer’s disease, hypothyroidism, and atherosclerotic heart disease, and an MDS BIMS score of three indicating severe cognitive impairment. On the date of the incident, a CNA observed R1’s room door closed, opened it, and saw another resident (R2) in his wheelchair next to R1’s bed. When the CNA returned with an LPN, they found R1’s brief lying next to her pillow, and R2 was removed from the room. Upon assessment, the LPN noted that R1 was naked from the waist down, with blood on the sheets, a moderate amount of blood in the vaginal area, and dried blood on the outer vaginal skin. R1 was sent to the hospital, where a SANE examination documented vaginal penetration with associated vaginal bleeding and a one-centimeter laceration to the left vaginal wall. R2’s medical record showed diagnoses including dependence on renal dialysis, end stage renal disease, cardiac arrhythmia, hypertension, and syncope and collapse, with an MDS BIMS score of five, also indicating severe cognitive impairment. A police department incident report documented that, when questioned by law enforcement, R2 stated he had positioned his wheelchair beside R1’s bed and placed his fingers into R1’s vagina, and the officer observed dried, stained blood on R2’s right finger. The Administrator stated there had been no indication of behaviors in R2’s past medical history that would have led the facility to decline his admission and that there was no indication of behaviors that would have triggered concern about such an outcome. The facility’s failure to ensure R1 was free from abuse and to maintain a safe and secure environment resulted in an Immediate Jeopardy determination related to the resident’s physical, mental, and psychosocial well-being.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.