Failure to Protect Resident From Sexual Abuse and to Immediately Report Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse and to immediately recognize and report an allegation of sexual abuse by a staff member. The facility’s abuse policy defined sexual abuse as non-consensual contact of any type with a resident, including unwanted intimate touching, and required all employees as mandated reporters to report allegations immediately, defined as as soon as possible but not later than two hours after an allegation is made. Despite this, a resident with diagnoses including bipolar disorder, agoraphobia, and anxiety disorder, and a care plan focus on impaired psychosocial well-being and feeling safe in the facility, reported sexually inappropriate touching and comments by a contracted NAC during peri-care. According to the facility’s investigation, the resident stated that the NAC entered their room to change their brief, stroked the inside of their thigh, commented that the resident was “hot,” made the peri area “very wet” with wipes, and responded to the resident’s objection by saying “that’s how it’s supposed to be.” The NAC also allegedly asked if the resident was single or married. The resident consistently repeated the same account of events, including specific details such as clothing color, and stated they would not feel comfortable if the NAC continued to work at the facility. The resident had previously informed another caregiver about feeling uncomfortable with the NAC’s care and comments, and that caregiver switched room assignments so the NAC would no longer care for the resident that day, but did not report the allegation or the reason for the room change to nursing staff. Staff interviews and documentation show that the allegation was not reported in accordance with the facility’s policy. One caregiver acknowledged being told by the resident that the NAC made them feel very uncomfortable, said they were skinny and beautiful, and provided peri-care differently—taking longer and being gentle—but only told the nurse they were switching rooms, without disclosing the resident’s statements. The LPN/Resident Care Manager documented the allegation the following day and reported being informed of the incident at the end of that day, and the DON stated they were notified later that same day by phone. During this time, the NAC reported having worked a double shift and providing care to the resident more than once, and stated they performed care alone and were unaware the resident required cares in pairs. The delay in recognizing and reporting the allegation meant the alleged perpetrator continued working with residents and retained access to the resident after the alleged sexual abuse.
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