Failure of Administration to Prevent, Recognize, and Properly Investigate Staff‑to‑Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility administration’s failure to provide protective oversight and to administer the facility in a manner that effectively prevents abuse, specifically staff‑to‑resident sexual abuse. The Administrator did not ensure appropriate supervision of an Environmental Services (EVS) housekeeper who entered and remained in resident rooms at unusual times without cleaning supplies or a housekeeping cart, causing residents to feel uncomfortable and afraid. The facility’s abuse policy required assigning responsibility for supervision of staff on all shifts to identify inappropriate staff behaviors, and the Administrator’s job description required protecting residents from abuse, ensuring reportable events are reported, and promoting an environment of trust and abuse prevention. Surveyors reviewed a police body‑worn camera recording of an interview conducted by the Administrator with a resident in the presence of a police officer. During this interview, the Administrator used leading and suggestive questions that implied the resident consented to sexual contact with the EVS housekeeper, including asking whether the resident “enjoyed” the act and whether it was something the resident “consent[ed]” to and “like[d]” to happen. The resident, who resided on a locked behavioral unit and referenced memory problems, responded that her “mind is gone” and could not state how long the conduct had been occurring, while also indicating the EVS housekeeper’s penis had been in her mouth several times. The Administrator later stated that this questioning style came from her professional training and that she believed the resident was alert, oriented, and communicating clearly during the interview. The five‑day follow‑up submitted by the facility concluded that staff‑to‑resident sexual contact was substantiated but characterized the incident as consensual and framed the EVS housekeeper’s responsibility as needing to inform administration of the resident’s desire for a sexual encounter. Additional findings showed that another resident on the same locked behavioral unit reported that the same EVS housekeeper had entered her room on two early‑morning occasions while she was dressing, without cleaning supplies, which she found odd and which made her feel uncomfortable; she reported this to the Social Service Director (SSD). The SSD acknowledged that she asked the resident if the EVS housekeeper had touched her, was told no, and did not file a grievance or conduct further investigation. A CNA reported that on the day of the incident she entered the first resident’s room while passing ice water and observed the EVS housekeeper standing with his pants down and his penis in the resident’s mouth; the CNA stated the EVS housekeeper exclaimed and ran into the bathroom, and that video review showed he had been in the room for fifteen minutes with a resident who has dementia. The Regional Director of Operations stated that the resident initiated the contact, that the incident was consensual, and simultaneously acknowledged that an employee receiving fellatio from a resident would violate the abuse policy. These actions and inactions by administration and leadership compromised the integrity of the abuse investigation and minimized the seriousness of staff‑to‑resident sexual abuse.
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