F0607

D

Failure to Implement Abuse Policy and Complete Required Employee Screening

Kingston, Pennsylvania Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse and Neglect Prevention Policy after an allegation of possible sexual assault involving one resident. The policy defined serious bodily injury to include sexual acts with a resident who is unable to consent or understand the nature of the act and required that, when maltreatment is suspected, the resident must be assessed for injuries and trauma, evidence must be preserved, and law enforcement and the State agency must be notified within specified time frames. The policy also directed staff not to bathe or clean the resident, not to wash or discard clothing or linens, not to destroy documentation, and to transfer the resident to the emergency department for medical examination, including a rape kit, when sexual abuse is suspected. In this case, the facility did not secure the scene, did not preserve potential evidence, did not ensure timely transfer for a sexual assault examination, and did not immediately notify law enforcement.

Resident 1, who had dementia and a BIMS score of 03 indicating severe cognitive impairment, was the alleged victim. Resident 2, the cognitively intact roommate with a BIMS score of 14 and a history of depression, hallucinations, and prior traumatic domestic violence, reported to staff that a male nurse aide (Employee 1) had possibly sexually assaulted Resident 1. Resident 2 stated that at approximately 5:00 AM she heard Employee 1 in the room and bathroom with Resident 1, heard him say phrases such as "we are going to get it right this time," "I am not going to hurt you," and that he would be gentle, and heard Resident 1 call him names. Resident 2 did not see sexual contact and did not hear Resident 1 express distress such as saying "stop," but believed a rape occurred based on Employee 1’s manner of speaking and Resident 1’s reactions when Employee 1 was present. Resident 2 reported the allegation of possible rape to the Activity Director around late morning, who then brought her to the Nursing Home Administrator (NHA). A progress note documented that a body audit of Resident 1 was completed and no visible injuries were observed, and a social services interview documented that Resident 1 denied inappropriate touching, pain, or genital symptoms.

Despite the facility’s policy requiring immediate police notification and prompt transfer for forensic medical evaluation when sexual abuse is suspected, the facility delayed both evidence preservation and external reporting. The NHA acknowledged that an allegation of possible rape was reported to her at approximately 11:00 AM, but law enforcement was not notified until 3:21 PM, several hours after the allegation was reported. Additionally, the resident was not transferred promptly for a sexual assault examination; instead, Resident 1 was bathed by a nurse aide on a later date to remove fecal matter from the private area, and the NHA’s account of when the responsible party was offered emergency room evaluation conflicted with the responsible party’s statement that no such option was offered during the initial visit and that staff repeatedly stated the incident did not occur. These actions and inactions resulted in failure to secure the scene, preserve potential forensic evidence, and ensure timely medical and forensic evaluation in accordance with the facility’s own abuse policy.

A separate but related deficiency involved the facility’s failure to follow its own employee screening procedures for one staff member. The facility’s Vulnerable Adult Abuse and Neglect Prevention Policy and Employment Screenings Policy required reasonable efforts to obtain information from previous employers, including verification of dates of employment, position held, and other reference information, or alternative references when prior employment was not available. Employee 1, the nurse aide implicated in the allegation, listed two previous employers on the employment application. However, review of the personnel file showed no documented evidence that reference checks or employment verifications were obtained from either prior employer before the employee’s start date. The Director of Human Resources confirmed that the facility could not provide documentation showing reasonable efforts to contact Employee 1’s previous employers, indicating that the facility did not implement its own screening procedures intended to identify any history of abuse, neglect, exploitation, or mistreatment.