F0610

G

Failure to Protect Resident From Suspected Sexual Abuse and Investigate Injuries of Unknown Origin

Galena, Kansas Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement protective measures and conduct timely assessment and investigation after injuries of unknown origin and signs of potential sexual abuse were identified for a cognitively impaired resident. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment with a BIMS score of three, dependence on staff for nearly all ADLs, and no documented prior skin conditions. Her care plan did not address the alleged perpetrator’s (AP’s) involvement in care and listed another son as DPOA, while the AP was treated as the primary caregiver and remained in the room with the resident almost continuously, often with the door closed. Staff had previously felt awkward and uncomfortable performing care with the AP present and reported that he frequently remained in the room, watched cares closely, and sometimes took over intimate care, but these concerns were not acted upon.

On the evening and night shift, CNAs observed significant bruising on the resident’s right leg and later vaginal bleeding, and reported these findings to the nurse. Around 10:30–11:00 PM, CNA staff reported significant bruising down the resident’s right leg to the nurse, who briefly assessed the bruises in the presence of the AP, accepted the AP’s explanation that the bruising might be from therapy or wheelchair positioning, and did not document the bruising in the EMR at that time. The resident was left alone in the room with the AP. Around 4:20 AM, CNA staff reported bright red blood in the resident’s brief and around the vaginal area to the same nurse, who did not assess the resident but instructed the CNA to apply antifungal cream or powder for a suspected yeast infection, again without further investigation or protective measures. The resident remained alone in the room with the AP with the door closed after care was completed.

On the following day shift, multiple staff continued to identify concerning findings without immediate protective action. At approximately 6:00 AM, the night nurse told two oncoming nurses that the resident had vaginal bleeding suspected to be from itching or yeast infection, but no assessment was done at that time. Around 8:00 AM, a CNA providing peri care with the AP present observed dried blood all over the vaginal area and reported it to a nurse, who assessed the resident at about 8:30 AM, noted dried blood, bruising on the labia and vaginal opening, and bruising on the hip, but attributed the injuries to itching and did not suspect abuse; the resident was again left in the room with the AP. Later that afternoon, a two-nurse assessment revealed extensive bruising on the right hip and leg, bruising and lacerations to the labia and vaginal area, bruising on the lower abdomen, and active vaginal bleeding, with the bruising on the hip described as resembling the shape of a hand. During this assessment the AP left the room, which staff noted was unusual. Witness statements documented that throughout this period the AP remained in the room during cares, the door was mostly closed, staff felt unsettled and had previously reported discomfort with the AP’s presence, and the resident made statements such as “why I let that man do that?” and “Son, why would you do this to me?” during or after care. Despite these observations and escalating physical findings, the resident remained alone in the room with the AP for approximately 16 hours after the initial report of bruising and subsequent vaginal bleeding before the situation was reported to administrative staff as potential abuse.

The EMR lacked timely documentation of the initial bruising and early vaginal bleeding, and a late entry note regarding the bruising was not entered until several days later, after surveyor interviews had begun. The facility’s abuse, neglect, and exploitation policy stated that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives, but staff did not remove or restrict the AP, did not initiate immediate protective measures when injuries of unknown origin and signs of possible sexual abuse were first identified, and did not promptly report or investigate the concerns. The deficiency was cited at a level of past noncompliance with actual harm, based on the existence of physical sexual abuse injuries that progressed while the resident was left alone with the AP and the likelihood of severe psychosocial trauma related to sexual abuse.