F0600

K

Failure to Protect Resident From Sexual Abuse and Delay in Investigation and Care Plan Updates

Hamburg, Pennsylvania Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident from sexual abuse and to ensure residents were free from such abuse, resulting in an Immediate Jeopardy situation. Facility policy defined sexual abuse as non-consensual sexual contact of any type and required implementation of an abuse prohibition program, including investigation of incidents and protection of residents during investigations, with social services assigned to monitor the resident’s feelings and involvement. The resident involved had diagnoses including muscle weakness, was interviewable without cognitive impairment per the MDS, and was dependent on staff for ADLs, including personal hygiene.

According to facility documentation, the resident reported that during evening incontinence care, a nurse aide cleaned her perineal area in a circular motion while asking, “Do you like that?” twice and flicking his tongue at her. The resident described that the aide folded and balled up multiple cleansing wipes and rubbed her vagina in an area she described as “the man in the boat,” in a circular motion, while repeatedly asking if she liked it and maintaining a fixed stare with continual tongue flicking. The resident stated she yelled at the aide twice not to say anything like that to her again, felt horrified, scared, singled out, and tearful, and reported that she had not previously observed any similar tongue or mouth behavior from the aide. Clinical records confirmed that the aide provided ADL care to the resident on the date of the alleged incident.

The facility’s investigative and protective actions were delayed and incomplete in the period immediately following the allegation. The resident reported she was not informed of any new interventions, options for interventions, or care plan updates until seven days after the initial allegation and was not aware of any measures implemented to protect her following the allegation. Documentation showed that the resident was provided victim’s rights information by police several days after the incident, and there was no evidence that her care plan was updated to address interventions to manage potential trauma until more than a week after the allegation. Additionally, although the facility interviewed residents and conducted physical assessments on residents on the unit where the resident lived, there was no evidence that residents or staff on another unit where the aide had also worked were interviewed or assessed as part of a thorough investigation until more than a week after the alleged incident, as confirmed by the Administrator.

Removal Plan

• Resident 1 was assessed and offered emotional support.
• Resident 1's plan of care was updated.
• Resident 1 will be followed by social services for emotional support and to determine indicators of post-traumatic stress disorder.
• The facility conducted interviews with staff and residents to identify any additional residents who may have been impacted.
• The police, Area Agency on Aging, and Pennsylvania Department of Aging were notified of the allegation of sexual abuse.
• The Administrator or designee re-educated the management team on conducting a thorough investigation.
• Staff were re-educated on reporting allegations of abuse or concerns about any staff member.
• All staff will be re-educated.
• Family members of non-interviewable residents will be contacted to identify any potential concerns of sexual misconduct.
• Identified concerns will initiate an immediate thorough investigation.
• Education on what constitutes a thorough investigation included ensuring the alleged perpetrator is suspended and residents are safe, obtaining statements from all staff who may have witnessed anything related to the incident, identifying all assignments or units where the perpetrator may have worked and interviewing all applicable residents, and reviewing the Abuse Critical Element Pathway throughout the investigation.
• The Director of Nursing or designee will conduct interviews with sampled residents and family members to identify any potential allegations of sexual misconduct.
• Any identified concerns from resident or family interviews will result in an immediate thorough investigation.
• The Market Operations Advisor educated the Clinical Lead on expectations for review of completed audits.
• The Director of Nursing or designee will conduct interviews of sampled staff members to identify any potential allegations of sexual misconduct.
• Any identified concerns from staff interviews will result in an immediate thorough investigation.
• The alleged perpetrator was suspended and will remain suspended until the investigation is completed.
• The facility will follow appropriate protocol per policy and legal requirements.
• If the alleged perpetrator returns to work, he will be re-educated on the abuse policy and have random observations of resident care.
• The results of the audits will be presented at the QAPI meetings for review.