Failure to Thoroughly Investigate and Report Substantiated Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an alleged and substantiated incident of sexual abuse between two cognitively impaired residents. One resident (R2), with CHF, stroke, traumatic brain injury, dysphagia, major depression, hypertension, bipolar disorder, weakness, and unsteady gait, had a BIMS score of 7 indicating moderate to severe cognitive impairment and required one-person assistance with ADLs. Another resident (R3), with CHF, adjustment disorder, vascular dementia without behavioral disturbance, unsteady gait, and gait abnormalities, had a BIMS score of 3 indicating severe cognitive impairment and also required one-person assistance with ADLs. Camera footage and staff observation documented that R3, while in his wheelchair near the nurse’s station, touched R2’s face, rubbed her back, and then repeatedly touched both of R2’s breasts before being separated by a CNA. The facility verified the incident by reviewing the hallway camera footage and obtaining a witness statement from the CNA who intervened, confirming that R3 touched both of R2’s breasts. However, the investigation was limited to these immediate observations and did not include interviews with other residents on the same household regarding R3’s inappropriate behaviors, comments, or touching of female residents. The record also did not show interviews with other staff working on that household about R3’s prior or ongoing inappropriate behaviors or comments toward female residents or staff, despite staff later reporting that R3 was flirty with female residents and staff, made sexually suggestive comments, and had been “a little hands on” with staff. The facility moved R3 from one alert hallway to another where other vulnerable female residents lived, but records showed no evidence of staff education related to this sexual abuse incident, even though this was not the first time R3 had exhibited inappropriate behaviors and comments. The facility did not contact law enforcement regarding the witnessed and video-recorded sexual abuse, with the Nursing Home Administrator stating that police were not called because both residents were cognitively impaired and providing no other explanation. The record review and interviews confirmed that the facility failed to conduct a thorough investigation, failed to interview potentially affected residents and staff, failed to provide education to staff regarding the incident, and failed to report the substantiated sexual abuse to the police as required by regulation.
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