Failure to Maintain Complete and Accurate Clinical Records After Resident-to-Resident Sexual Incidents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents involved in alleged resident-to-resident sexual incidents. For one incident, facility documentation and an Event Reporting System (ERS) submission indicated that a resident (CR1) was found in another resident's (8) room, where the second resident was completely naked. Witness statements documented that the first resident admitted to removing the second resident's clothing, removing his own pants, and rubbing his penis against the second resident's side after stating he wanted to have sex with her. ERS and hospital records showed that the second resident was sent to the hospital for possible evaluation of sexual assault and remained overnight for observation in the emergency room. Despite these events, review of the second resident's clinical record revealed no nursing assessment documented after the alleged sexual abuse and prior to her transfer to the hospital, and no documentation in her clinical record related to the incident itself. In a separate incident reported through ERS, another resident was observed rubbing a sleeping resident's genital area over her clothing while she was in a geri-lounger in a common area. Review of the first resident's clinical record showed only a social services note referencing follow-up for "recent behaviors" but no documentation specifically describing or relating to the observed genital touching incident. These omissions demonstrated that the facility did not ensure clinical records were complete and accurate for the residents involved.
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