State cites Hughes Center for poor supervision of residents, poor handling of sexual misconduct

The Virginia Department of Behavioral Health and Developmental Services (DBHDS) conducted an investigation and site inspection into allegations of suspected sexual encounters and possible child abuse between two residents at the Hughes Center for Exceptional Children. The investigation revealed eight violations of state regulations related to the reporting and handling of sexual encounters among residents, including: failure to report suspected cases of child abuse and neglect to local CPS [Child Protective Services] or a regulator, placing agency, or parent/guardian;failure to provide supervision or protection; failure to monitor and evaluate service quality; noncompliance with documenting treatment progress goals; noncompliance with human rights regulations; and failures to provide follow up medical care.

During the inspection, the DBHDS found that the provider had placed a “Sexual Aggressor” resident in the same living area with a resident who expressed interest in engaging in sexual activity. The DBHDS report noted:

“Consumer 1 and Consumer 3  engaged in sexual activity while Consumer 1 was on Sexual Aggressor Precautions which required 15 minute checks by staff. The fact that the consumers were unsupervised for at least 12 minutes and had the opportunity to engage in sexual activity indicates the Consumers were not adequately supervised or protected.”

The inspection also revealed that the facility failed to document progress towards meeting patient treatment goals for the resident placed on Sexual Aggressor Precautions (SAP). DBHDS found, “a physician note dated February 25, 2014 indicates Consumer 1 made inappropriate sexual comments during group therapy… However, therapist notes for this date do not reflect the inappropriate behavioral occurred or how the inappropriate behavior was address by therapist with the Consumer.”

DBHDS also found that the facility failed to provide follow up medical services and treatment. During the record review, DBHDS could not find documented evidence that a Consumer was tested for Sexually Transmitted Diseases (STDs) after acknowledging having sex with another Consumer. The DBHDS report stated:

“Consumer 3 revealed engaging in sexual activity with Consumer 1 on March 3, 2014. Available nursing notes from March 6, 2014 indicated that… Consumer complained of burning when urinating. Labs were ordered and results obtained. However, Consumer 3’s record did not contain documented evidence that the Provider provided Consumer 3 with the required medial follow up as there is no documented evidence that the lab results were reviewed by the physician or shared with Consumer or the Consumer’s legal guardian.”

Additionally, the facility was cited for Human Rights violations for noncompliance with the complaint resolution process. The DBHDS found that the Authorized Representative’s for both residents were not given preliminary decisions regarding the facility’s investigation into the sexual misconduct allegations, and  “nor were the ARs [Authorized Representatives] given the option to access the complaint resolution process due to the lack of receiving the proper written complaint findings.”

In the provider’s response, the facility ensures that it now reports all sexual encounters to the appropriate agencies and guardians and that all clinical staff abides by facility policies. Specifically, the Facility Clinical Director agreed to provide training to the facility clinical staff on the policies regarding elevated precautions for residents. Lastly, the provider will ensure that all necessary elements of the policy are delivered and documented in the resident record.