Failure to Protect Resident From Sexual Abuse and Inadequate Safeguards During Investigation
Penalty
Summary
Administration failed to maintain an environment free from sexual abuse and to provide adequate protection during the investigation of an alleged sexual abuse incident involving two residents sharing a room. The Administrator’s job description assigned responsibility for directing day-to-day operations in compliance with regulations and assuming responsibility for procedural guidelines related to prevention and reporting of patient abuse, while the DON’s job description assigned responsibility for directing nursing services in accordance with applicable regulations. Despite these responsibilities, after an allegation that one resident sexually abused their roommate, the facility did not remove the alleged aggressor from the room or otherwise separate the residents at the time of the incident. The Administrator later stated that the facility did not send the alleged victim to the ER because the NP did not issue an order to do so and only ordered a psychiatry referral. The DON reported that evening staff notified her of the incident and explained the interventions that had been put in place, including hourly monitoring, which she initially considered appropriate because the alleged aggressor had not previously exhibited such behavior and was described as usually well-mannered. The Administrator stated she decided to implement hourly monitoring and believed the facility had done everything needed to keep the alleged victim safe, emphasizing that the alleged aggressor had no prior history of such behavior. However, both residents continued to reside in the same room from the date of the incident until surveyors questioned the Administrator about placement options for the alleged aggressor, at which point the alleged victim was moved to a different room. The noncompliance was determined to have the likelihood to cause serious injury, harm, impairment, or death and was identified as Immediate Jeopardy beginning on a specific date.
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