Failure to Supervise Resident With Known Sexual Behaviors Resulting in Sexual Abuse of a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident with known sexually inappropriate behaviors. One resident (R2) had a documented history of making sexual comments, attempting to touch staff’s buttocks, and inappropriately touching female residents, including a prior incident of grabbing a female resident’s chest and using vulgar language toward staff and residents. R2’s comprehensive care plan specified that he must be escorted to and from activities, kept at least an arm’s length away from all female residents, monitored when in common areas, and kept out of arm’s reach from female residents. Staff interviews confirmed that, prior to the incident, R2 was to be in staff line of sight whenever out of his room and not left around female residents. The victim, R1, was a severely cognitively impaired, nonverbal resident with autism and metabolic encephalopathy, identified in her care plan as vulnerable due to limited speech and inability to call out for help or remove herself from unsafe situations. Her care plan included the need to provide a safe environment. On the date of the incident, R2 was observed in a lounge area with R1, with his hand on her in a way that appeared to be touching her private area. A CNA reported seeing R2 touching R1 in the abdomen area when returning from putting trays on the cart. Staff immediately separated the two residents and notified the RN on duty. Interviews and record review showed that R2 was left unsupervised in the lounge with R1 despite his care plan requirements for close supervision and restrictions around female residents. The CNA involved, who was agency staff, later reported she believed R2’s extra supervision was required only during mealtimes, indicating that she did not follow or was not aware of the full supervision requirements outlined in R2’s care plan and Kardex. The surveyors determined that the facility failed to provide adequate supervision and to follow R2’s care plan interventions to keep him out of arm’s reach of female residents and under monitoring in common areas, resulting in an incident of sexual touching of a nonverbal, severely cognitively impaired resident who could not consent or protect herself. This failure led to a finding of immediate jeopardy beginning on the date of the incident.
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