F0607

J

Failure to Implement Abuse Policy and Offer Timely Emergency Transport After Alleged Sexual Assault

Temple, Texas Survey Completed on 01-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to fully implement its written abuse, neglect, exploitation, and misappropriation prevention policies in response to an alleged sexual assault between two residents. The facility’s policy, revised April 2021, states residents have the right to be free from abuse and neglect, requires protection from abuse by other residents, mandates identification and investigation of all possible incidents of abuse, and requires protection of residents from further harm during investigations. Despite these written policies, the facility did not ensure that a cognitively impaired, nonverbal female resident was offered emergency transportation services for medical evaluation immediately after she was found in bed with a male resident who was on top of her and gyrating his hips.

The female resident had dementia, anxiety disorder, major depressive disorder, pain disorder, gait and mobility abnormalities, and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. Her MDS showed she was unable to complete a BIMS interview and had short- and long-term memory problems, with moderately impaired decision-making. Her care plan documented wandering into other residents’ rooms and lying in other residents’ beds, with interventions including redirection and protection of other residents’ rights and safety. On the date of the incident, staff notes documented that she was found in bed with another resident, that staff intervened and separated them, and that she was nonverbal but calm and cooperative. A head-to-toe and skin assessment documented no injuries or signs of penetration, but dried feces were noted on her pubic hair. Another psychosocial note described her as being in a male resident’s room with the male on top of her gyrating his hips, after which residents were separated and vital signs were within normal limits.

The male resident involved had vascular dementia, schizophrenia, and auditory and visual hallucinations, and resided on the secure unit due to wandering and poor safety awareness. His MDS showed he was cognitively intact by BIMS score, independent in mobility and lower body dressing, and his care plan required monitoring and reporting changes in behavior. A change in condition note documented that he was observed lying in bed next to a female resident when staff intervened. An administrative note recorded that a medication aide entered his room, found him in bed with the female resident, his pants down with genitalia exposed, and the female resident’s pants down with her brief intact, and that he was immediately redirected and placed on 1:1 monitoring. The facility’s self-report and incident documentation focused on the event and internal assessments but did not reflect that the female resident was offered immediate emergency transport for medical evaluation after the alleged sexual assault.

Subsequent documentation showed that the female resident was ultimately transported to the hospital by EMS for medical clearance related to possible STI exposure, but this occurred only after her family requested transfer two days after the incident. The hospital record indicated she presented for medical clearance due to a recent history of possible abuse, with the family reporting that a co-resident had been found on top of her in bed several days earlier. Interviews with the resident’s family and MPOA confirmed they were notified by staff of a male resident being found on top of her with clothing off, and that they later discovered she had not been sent to the hospital at the time of the incident and had to request that she be transferred. The survey findings state that the facility failed to implement written policies and procedures in response to the sexual assault in that the resident was not offered emergency transportation services after the abuse incident, contributing to the cited deficiency under the requirement to develop and implement policies and procedures to prevent abuse, neglect, and theft.