Failure of Administration and Nursing Leadership to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to protect residents from resident-to-resident sexual abuse. The NHA job description requires managing the facility in accordance with applicable federal, state, and local standards and regulations, following all facility policies uniformly, and ensuring the highest degree of quality care for residents at all times. The DON job description requires planning, organizing, developing, and directing the overall operation of the nursing service department in accordance with current standards, guidelines, and regulations, and as directed by the Administrator and Medical Director, to ensure the highest degree of quality care is maintained. Based on review of job descriptions, clinical records, and staff interviews, surveyors determined that the NHA and DON did not fulfill these essential duties, as the facility failed to prevent and protect residents from resident-to-resident sexual abuse. Specifically, a resident with a known history of sexually inappropriate behavior engaged a non-consenting resident, affecting one of 44 residents (identified as Resident R2). During an interview, the NHA and DON confirmed that they failed to effectively manage the facility to protect residents from resident-to-resident sexual abuse for this resident. The cited regulatory references include 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
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