Failure to Investigate and Report Resident-to-Resident Sexual, Physical, and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, investigate, log, and respond appropriately to multiple resident-to-resident altercations, including alleged sexual, physical, and verbal abuse. Facility policy required immediate investigation of any suspicion or report of abuse, thorough documentation, and reporting to the state survey agency, with an Abuse Prevention Coordinator designated to oversee these processes. Despite this, the facility did not treat several documented incidents as reportable allegations of abuse and did not initiate investigations or protective measures as required. For one resident with dementia, confusion, wandering, and intrusive behaviors, progress notes documented that this resident was grabbing and touching various staff and residents, hitting staff and residents, touching another resident’s buttocks, and grabbing another resident’s coat as they walked by. These notes did not indicate what was done to protect other residents, whether staff identified who the affected residents were, whether notifications were made, or whether the incidents were reported or investigated. The facility’s abuse log for the relevant month contained no entries for these events. Another cognitively intact resident reported that this same resident spanked their buttocks while they were bending over to get condiments from a coffee cart; the nurse’s note documented the report and that it was relayed to the DON, but again did not show any protective actions, notifications, reporting, or investigation. A later incident involved another cognitively intact resident who reported that the same behaviorally impaired resident grabbed their breasts near an elevator. An investigation was completed for this single event, including interviews, and concluded that the behavior was related to dementia and was considered behavioral rather than intentional abuse, with abuse ruled out. However, this investigation did not identify or incorporate the prior documented inappropriate touching incidents, and those earlier events were not logged, reported, or investigated as abuse allegations. The deficiency also includes unaddressed physical abuse between roommates. One cognitively intact resident reported to an LPN that they had a physical altercation with their roommate, resulting in scratches on their left arm. The nurse documented the report, the presence of scratches, the offer of a room move, and provider notification, but there was no documentation of actions taken to protect either resident, prevent further abuse, or any indication that the incident was reported, logged, or investigated. Progress notes for the roommate over the same period contained no documentation of the altercation or staff response, and the facility’s abuse log for that month had no entries related to this physical altercation. Additionally, the facility failed to address resident-to-resident verbal abuse as an allegation of abuse. One cognitively intact resident was documented as being verbally aggressive and demeaning toward their roommate, calling them derogatory names, stating the roommate smelled, and expressing disgust that the roommate needed to be changed in bed. The nurse documented that the verbally aggressive resident was offered and accepted a room change and had no further concerns, but the note did not indicate who was notified, nor whether the verbal abuse was reported, logged, or investigated as required by facility policy. Across these events, the facility did not follow its abuse, neglect, and exploitation policy to treat these incidents as allegations of abuse requiring reporting, investigation, and preventive measures.
Removal Plan
- Conducted resident and staff interviews
- Ensured residents with sexual behaviors were placed on one-on-one supervision
- Re-educated all staff regarding abuse policies/procedures
- Ensured an effective system was in place to safeguard, protect and prevent residents at risk for abuse
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