Failure to Provide Timely Trauma-Informed, Person-Centered Care After Alleged Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to assess triggers and develop and implement an individualized, person-centered plan to provide trauma-informed care for a resident following an allegation of sexual abuse. The resident had muscle weakness, was dependent on staff for ADLs including personal hygiene, and was documented as interviewable without cognitive impairment on the MDS. Facility documentation showed that the resident reported that during evening incontinence care, a nurse aide cleaned her perineal area in a circular motion while twice asking, “Do you like that?” and flicking his tongue at her. The resident described that the aide rubbed her vagina where the labia begin with balled-up cleansing wipes in a circular motion, repeatedly asked if she liked it, and maintained a fixed stare while flicking his tongue, leading her to yell at him not to say anything like that again and to think of how to call for help. The resident later reported feeling horrified, scared, singled out, and that the vision of the aide during the encounter would stay with her; she was tearful multiple times during the interview and expressed distress that her family had to read about the incident. A visitor also reported that the resident had been negatively impacted psychosocially by the alleged incident. Although the record showed that social services spoke with the resident about inappropriate comments made by a staff member, there was no evidence that the facility conducted a thorough assessment to identify the resident’s trauma related to the physical and verbal aspects of the alleged sexual abuse, or to identify triggers and prevent re-traumatization. There was also a lack of evidence that new interventions, options for additional interventions, or updates to the care plan were discussed with the resident in a timely manner, and no evidence that new, person-centered interventions for trauma-informed care were implemented until several days after the allegation.
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