Supervisors at CareOne at Peabody nursing home failed to investigate several credible reports of incidents of sexual abuse by a resident this year, at one point telling a nurse who reported one incident that “nothing happened,” according to an investigation by the Massachusetts Department of Public Health. Despite the repeated incidents — at least nine over a five-week period in August and September against four different residents — CareOne failed to investigate or report them to the state, the report said. State inspectors uncovered the abuse after responding to a complaint in early November. The agency said the nursing home failed to ensure that residents were protected from abuse.
The reported abuse included the resident grabbing other residents by the genitals, forcibly rubbing up against them, pinning them against a wall, and pulling them onto a bed. After one incident, a resident who had been abused several times “buried his/her face into (a nurse’s) shoulder and cried,” the report said. The investigation discovered at least nine separate incidents when workers at CareOne witnessed the same resident abusing four other residents. The victims all suffer from dementia.
CareOne’s administrator and director of nursing resigned in disgrace in the wake of the investigation, and the resident accused of committing the abuse has been discharged from the nursing home, according to the report.
In at least three of the instances, supervisors appeared to ignore the incidents or diminish their seriousness. In one case, the director of nursing told a nurse to change his description of an incident on his witness statement from “grabbing” to “hugging.” In another incident, a unit manager told a nurse that “nothing happened” because staff had intervened when the resident tried to pull another resident onto a bed.
On Sept. 7, an activities aide saw the resident grab another resident’s genital area in the dining room, according to the report. When the aide told the director of nursing, the director said she wanted to determine for herself if the resident exhibited inappropriate sexual behaviors.
According to several witnesses, the director of nursing said she was going to “flaunt myself” in front of the resident to see if he or she would do anything (residents’ genders are not given in the report). A family member told investigators that the director of nursing “stuck her breasts forward while swaying her shoulders back and forth in front of Resident #1.”
When Resident #1 did not react, the director of nursing instructed staff to bring back the resident who had just been grabbed by Resident #1 to see if Resident #1 would do anything else. When Resident #1 reached over and pulled the other resident’s chair closer, the director of nursing intervened.
Witnesses said the director of nursing, who is not named, also asked the resident why he or she paid attention to the victim, who the director said was “not attractive.” A witness said everyone at the table could hear that remark.
What is wrong with the Director of Nursing?